Healthcare Provider Details

I. General information

NPI: 1629702899
Provider Name (Legal Business Name): SHAMI GOKHALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 10/17/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 ATL HIGHWAY
LOGANVILLE GA
30052
US

IV. Provider business mailing address

2210 CEDAR PLACE CT
SNELLVILLE GA
30078-3312
US

V. Phone/Fax

Practice location:
  • Phone: 678-367-4615
  • Fax:
Mailing address:
  • Phone: 408-669-7959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN122835
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: