Basic Information
| Provider Information | |||||||||
| NPI: | 1043257322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAFIEHA | ||||||||
| FirstName: | EBRAHIM | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4224 PINEHURST CIRCLE | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094777507 | ||||||||
| FaxNumber: | 2094777507 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 E HAMMER LANE | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099579500 | ||||||||
| FaxNumber: | 2099579508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 43395 | CA | Y | Dental Providers | Dentist |
No ID Information.