1093116824 NPI number — DR. SHADOW ASGARI DDS

Table of content: DR. SHADOW ASGARI DDS (NPI 1093116824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093116824 NPI number — DR. SHADOW ASGARI DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ASGARI
Provider First Name:
SHADOW
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093116824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 W RAY RD
Provider Second Line Business Mailing Address:
SUITE 14
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85226-5940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-812-8200
Provider Business Mailing Address Fax Number:
480-812-8552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3336 E CHANDLER HEIGHTS RD
Provider Second Line Business Practice Location Address:
BLDG 2 SUITE 111
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85298-4259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-988-0028
Provider Business Practice Location Address Fax Number:
480-988-6414
Provider Enumeration Date:
09/11/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D05715 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)