Healthcare Provider Details

I. General information

NPI: 1750086468
Provider Name (Legal Business Name): SIMI SHAH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 HIGHWAY 54 W STE 315
FAYETTEVILLE GA
30214-4572
US

IV. Provider business mailing address

1240 HIGHWAY 54 W STE 315
FAYETTEVILLE GA
30214-4572
US

V. Phone/Fax

Practice location:
  • Phone: 770-478-6878
  • Fax:
Mailing address:
  • Phone: 352-201-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN123928
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: