Provider Demographics
NPI:1245023050
Name:TAHERI, SHAHAB (DMD)
Entity type:Individual
Prefix:
First Name:SHAHAB
Middle Name:
Last Name:TAHERI
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 1:315 SHALLOWFORD PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-6209
Mailing Address - Country:US
Mailing Address - Phone:502-767-9018
Mailing Address - Fax:
Practice Address - Street 1:880 EASTGATE NORTH DR STE 101
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-2051
Practice Address - Country:US
Practice Address - Phone:502-767-9018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-24
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.028033122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist