Provider Demographics
NPI:1487921805
Name:SHAFA, FARHAD (DDS)
Entity type:Individual
Prefix:DR
First Name:FARHAD
Middle Name:
Last Name:SHAFA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 S ROBERTSON BLVD
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1404
Mailing Address - Country:US
Mailing Address - Phone:310-858-2652
Mailing Address - Fax:310-858-2658
Practice Address - Street 1:1140 S ROBERTSON BLVD
Practice Address - Street 2:SUITE # 1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1404
Practice Address - Country:US
Practice Address - Phone:310-858-2652
Practice Address - Fax:310-858-2658
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist