Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DS041118 | PA |
Y | 1223P0300X | Periodontist | 105586 | CA |
NPI | 1144600289 |
---|---|
Provider Name | Dr. Shadie R Azar |
First Address | Upland, CA 91786-6685 |
Second Address | Upland, CA 91786-6685 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2015 |
Last Update Date | 12/01/2021 |