Provider Demographics
NPI:1871700385
Name:DADGARIAN SHOUSHTARI, BANAFSHEH (DMD, FAGD)
Entity type:Individual
Prefix:DR
First Name:BANAFSHEH
Middle Name:
Last Name:DADGARIAN SHOUSHTARI
Suffix:
Gender:F
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CORPORATE PLAZA DR STE 175
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7949
Mailing Address - Country:US
Mailing Address - Phone:949-706-6737
Mailing Address - Fax:949-706-6740
Practice Address - Street 1:2 CORPORATE PLAZA DR STE 175
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7949
Practice Address - Country:US
Practice Address - Phone:949-706-6737
Practice Address - Fax:949-706-6740
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist