Healthcare Provider Details

I. General information

NPI: 1063276921
Provider Name (Legal Business Name): SHUBHAM SHARMA BDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 08/04/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 MARTIN LUTHER KING JR BLVD
DETROIT MI
48208-2576
US

IV. Provider business mailing address

2700 MARTIN LUTHER KING JR BLVD
DETROIT MI
48208-2576
US

V. Phone/Fax

Practice location:
  • Phone: 313-494-6763
  • Fax:
Mailing address:
  • Phone: 313-494-6763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901602790
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: