Provider Demographics
NPI:1174352363
Name:SETOUDEHMARAM, SHAHIN
Entity type:Individual
Prefix:
First Name:SHAHIN
Middle Name:
Last Name:SETOUDEHMARAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SPRING GARDEN ST UNIT 610
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-3839
Mailing Address - Country:US
Mailing Address - Phone:424-542-4977
Mailing Address - Fax:
Practice Address - Street 1:14207 COIT RD STE 112
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-2839
Practice Address - Country:US
Practice Address - Phone:888-676-2327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX409151223X0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program