Provider Demographics
NPI:1487931598
Name:MAHALLATI, SHAHIN (DDS)
Entity type:Individual
Prefix:
First Name:SHAHIN
Middle Name:
Last Name:MAHALLATI
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 1:653 CAMINO DE LOS MARES STE 113
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2856
Mailing Address - Country:US
Mailing Address - Phone:949-248-7772
Mailing Address - Fax:949-248-0516
Practice Address - Street 1:653 CAMINO DE LOS MARES STE 113
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2856
Practice Address - Country:US
Practice Address - Phone:949-248-7772
Practice Address - Fax:949-248-0516
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA431941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice