Healthcare Provider Details

I. General information

NPI: 1023364288
Provider Name (Legal Business Name): SHAHNAM ALEXANDER SHIFTEH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 HOLIDAY CT
RIVER VALE NJ
07675-5708
US

IV. Provider business mailing address

16 HOLIDAY CT
RIVER VALE NJ
07675-5708
US

V. Phone/Fax

Practice location:
  • Phone: 201-264-5270
  • Fax:
Mailing address:
  • Phone: 201-264-5270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number056166
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: