Provider Demographics
NPI:1316134893
Name:SHANABO, SHAZA (DDS)
Entity type:Individual
Prefix:MRS
First Name:SHAZA
Middle Name:
Last Name:SHANABO
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 1:323 CALLE MORENO
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3991
Mailing Address - Country:US
Mailing Address - Phone:909-438-4567
Mailing Address - Fax:
Practice Address - Street 1:14607 RAMONA BLVD STE B
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3465
Practice Address - Country:US
Practice Address - Phone:626-960-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48548122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist