Healthcare Provider Details

I. General information

NPI: 1639160559
Provider Name (Legal Business Name): SHAILA VASA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 NASSAU RD
ROOSEVELT NY
11575-1736
US

IV. Provider business mailing address

257 NASSAU RD
ROOSEVELT NY
11575-1736
US

V. Phone/Fax

Practice location:
  • Phone: 516-868-1892
  • Fax: 516-868-1892
Mailing address:
  • Phone: 516-868-1892
  • Fax: 516-868-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number034156
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: