Provider Demographics
NPI:1124421334
Name:MOHAZAB, SHIVA (DDS)
Entity type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:MOHAZAB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16011 BUTTERFIELD RANCH RD UNIT 235
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-7456
Mailing Address - Country:US
Mailing Address - Phone:310-597-1411
Mailing Address - Fax:
Practice Address - Street 1:24634 MADISON AVE STE E
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-600-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1014261223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty