Provider Demographics
NPI:1366576332
Name:KHANIDEH, SHABNAM (DMD)
Entity type:Individual
Prefix:
First Name:SHABNAM
Middle Name:
Last Name:KHANIDEH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15720 VENTURA BLVD
Mailing Address - Street 2:SUITE 609
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2914
Mailing Address - Country:US
Mailing Address - Phone:818-385-3500
Mailing Address - Fax:818-788-7303
Practice Address - Street 1:15720 VENTURA BLVD
Practice Address - Street 2:SUITE 609
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2914
Practice Address - Country:US
Practice Address - Phone:818-385-3500
Practice Address - Fax:818-788-7303
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54944122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist