MEDICARE: KHILNNA SHAH D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D012238	AZ

General Provider Information

NPI Number	:	1255176467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHILNNA SHAH D.M.D

Provider Business Mailing Address
First Line	:	5414 W BECKER LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-4212
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5414 W BECKER LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-4212
Country	:	US
Telephone Number	:	623-265-8965
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2024
Last Update Date	:	06/28/2024

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