Provider Demographics
NPI:1528294709
Name:SHADI, JONATHAN R (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:R
Last Name:SHADI
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 1:12300 WILSHIRE BLVD
Mailing Address - Street 2:STE 326
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1020
Mailing Address - Country:US
Mailing Address - Phone:310-954-9449
Mailing Address - Fax:310-954-9470
Practice Address - Street 1:12300 WILSHIRE BLVD
Practice Address - Street 2:STE 326
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-954-9449
Practice Address - Fax:310-954-9470
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA588121223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery