MEDICARE: ISHAN SHAH

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	1223G0001X	General Practice Dentistry	40452	TX

General Provider Information

NPI Number	:	1265133789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISHAN SHAH

Provider Business Mailing Address
First Line	:	7703 FLOYD CURL DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3901
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2439 MONARCH DR UNIT 4
Second Line	:
City	:	LAREDO
State	:	TX
Zip	:	78045-6840
Country	:	US
Telephone Number	:	956-723-1230
Fax Number	:

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

Provider Enumeration Date	:	03/13/2023
Last Update Date	:	07/05/2024

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Directions to “ ISHAN SHAH ” Practice Location

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