Healthcare Provider Details

I. General information

NPI: 1073787487
Provider Name (Legal Business Name): SHAMIK SURESH VAKIL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 IVERSON WAY
CHARLOTTE NC
28203-5631
US

IV. Provider business mailing address

3326 SISKEY PKWY STE 310 #310
MATTHEWS NC
28105-3226
US

V. Phone/Fax

Practice location:
  • Phone: 704-741-7469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8667
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: