Healthcare Provider Details

I. General information

NPI: 1821782269
Provider Name (Legal Business Name): SHAILI SHAH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 COUNTY ROAD 210 W STE A2-A3
SAINT JOHNS FL
32259-1300
US

IV. Provider business mailing address

10714 TWIN OVERLOOK PL
LAUREL MD
20723-2071
US

V. Phone/Fax

Practice location:
  • Phone: 904-621-6568
  • Fax:
Mailing address:
  • Phone: 240-406-6860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN32410
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: