Provider Demographics
NPI:1104966332
Name:KHODAI, SHAHRAM (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAHRAM
Middle Name:
Last Name:KHODAI
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 1:3984 DOUGLAS BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4245
Mailing Address - Country:US
Mailing Address - Phone:916-771-0330
Mailing Address - Fax:916-880-5354
Practice Address - Street 1:3984 DOUGLAS BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4245
Practice Address - Country:US
Practice Address - Phone:916-771-0330
Practice Address - Fax:916-880-5354
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA430271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice