Provider Demographics
NPI:1215066329
Name:YAFAI, MARK SHAHRAM (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:SHAHRAM
Last Name:YAFAI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16661 VENTURA BLVD
Mailing Address - Street 2:SUITE # 215
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1914
Mailing Address - Country:US
Mailing Address - Phone:310-892-1969
Mailing Address - Fax:
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:SUITE # 215
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1914
Practice Address - Country:US
Practice Address - Phone:310-892-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA501171223S0112X, 204E00000X
CAA104572204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery