Provider Demographics
NPI:1104978147
Name:KHASATI, SHADI KAMEL (DDS)
Entity type:Individual
Prefix:DR
First Name:SHADI
Middle Name:KAMEL
Last Name:KHASATI
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 1:32862 FALMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7641
Mailing Address - Country:US
Mailing Address - Phone:909-213-5196
Mailing Address - Fax:951-302-2422
Practice Address - Street 1:44066 MARGARITA RD
Practice Address - Street 2:SUITE 1
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2779
Practice Address - Country:US
Practice Address - Phone:951-302-6222
Practice Address - Fax:951-302-2422
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist