Healthcare Provider Details

I. General information

NPI: 1770966079
Provider Name (Legal Business Name): SYED IMRAN SHAH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2015
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12165 ELM ST
PRINCESS ANNE MD
21853-1358
US

IV. Provider business mailing address

PO BOX 1978
SALISBURY MD
21802-1978
US

V. Phone/Fax

Practice location:
  • Phone: 410-651-5151
  • Fax: 410-651-4256
Mailing address:
  • Phone: 410-749-1015
  • Fax: 410-749-0654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS041051
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18640
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: