Healthcare Provider Details

I. General information

NPI: 1144568601
Provider Name (Legal Business Name): TOOTHTIMEDENTALSTUDIOPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 JERICHO TPKE SUIT #2
NEW HYDE PARK NY
11040-4510
US

IV. Provider business mailing address

PO BOX 81 ALBERTSON
ALBERTSON NY
11507-0081
US

V. Phone/Fax

Practice location:
  • Phone: 516-519-8080
  • Fax: 516-519-8082
Mailing address:
  • Phone: 516-519-8080
  • Fax: 516-519-8082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: SEJAL U SHAH
Title or Position: PRESIDENT
Credential: DDS
Phone: 515-519-8080