Provider Demographics
NPI:1144384793
Name:GHODSI, SHAYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:SHAYAN
Middle Name:
Last Name:GHODSI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9375 WEST SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065
Mailing Address - Country:US
Mailing Address - Phone:617-512-6116
Mailing Address - Fax:
Practice Address - Street 1:9375 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4101
Practice Address - Country:US
Practice Address - Phone:954-341-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist