Healthcare Provider Details

I. General information

NPI: 1366985491
Provider Name (Legal Business Name): JESAL SHAH, DMD, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4609 5TH AVE 2ND FLOOR
BROOKLYN NY
11220-1207
US

IV. Provider business mailing address

4609 5TH AVE 2ND FLOOR
BROOKLYN NY
11220-1207
US

V. Phone/Fax

Practice location:
  • Phone: 718-854-3191
  • Fax: 718-909-1635
Mailing address:
  • Phone: 718-854-3191
  • Fax: 718-909-1635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number052986
License Number StateNY

VIII. Authorized Official

Name: DR. JESAL SHAH
Title or Position: PRESIDENT
Credential: DMD
Phone: 516-395-2659