Healthcare Provider Details

I. General information

NPI: 1114309309
Provider Name (Legal Business Name): SHAMIK NAVIN DESAI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 E 14TH ST APT MA
NEW YORK NY
10009-2823
US

IV. Provider business mailing address

453 E 14TH ST APT MA
NEW YORK NY
10009-2823
US

V. Phone/Fax

Practice location:
  • Phone: 860-490-7058
  • Fax:
Mailing address:
  • Phone: 860-490-7058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02521600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: