Provider Demographics
NPI:1669964870
Name:JEBRAEILI, SHADZI (DMD, MS, ORTHO CERT)
Entity type:Individual
Prefix:
First Name:SHADZI
Middle Name:
Last Name:JEBRAEILI
Suffix:
Gender:F
Credentials:DMD, MS, ORTHO CERT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BEAVERBROOK CRESCENT
Mailing Address - Street 2:
Mailing Address - City:MAPLE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L6A3T2
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8210 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3923
Practice Address - Country:US
Practice Address - Phone:210-450-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX316691223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice