Healthcare Provider Details

I. General information

NPI: 1962969022
Provider Name (Legal Business Name): SHILP DALAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 STATE ROUTE 18 S STE B
EAST BRUNSWICK NJ
08816-1904
US

IV. Provider business mailing address

1631 PATERSON PLANK RD APT 312
SECAUCUS NJ
07094-4172
US

V. Phone/Fax

Practice location:
  • Phone: 732-955-0709
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02805900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: