Provider Demographics
NPI:1932736774
Name:HELAIRE, EBONY SHARDAE
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:SHARDAE
Last Name:HELAIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 MOKELUMNE DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-9057
Mailing Address - Country:US
Mailing Address - Phone:510-755-6824
Mailing Address - Fax:
Practice Address - Street 1:415 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-6004
Practice Address - Country:US
Practice Address - Phone:707-558-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1068151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program