Healthcare Provider Details

I. General information

NPI: 1710377494
Provider Name (Legal Business Name): DR SRUJAL H SHAH DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 SCOTTS VALLEY DR STE H
SCOTTS VALLEY CA
95066-4541
US

IV. Provider business mailing address

6120 HELLYER AVE STE 125
SAN JOSE CA
95138-1066
US

V. Phone/Fax

Practice location:
  • Phone: 408-490-0182
  • Fax: 408-624-4545
Mailing address:
  • Phone: 408-490-0182
  • Fax: 408-624-4545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number58754
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: SRUJAL HARSHAD SHAH
Title or Position: PRESIDENT
Credential: DDS
Phone: 408-490-0182