Provider Demographics
NPI:1215192422
Name:AZADI, SHAHLA (DDS)
Entity type:Individual
Prefix:
First Name:SHAHLA
Middle Name:
Last Name:AZADI
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 1:3004 FALLEN OAK RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-8660
Mailing Address - Country:US
Mailing Address - Phone:304-594-2712
Mailing Address - Fax:
Practice Address - Street 1:3004 FALLEN OAK RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-8660
Practice Address - Country:US
Practice Address - Phone:304-594-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037558122300000X
WV3840122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist