Healthcare Provider Details

I. General information

NPI: 1043654098
Provider Name (Legal Business Name): ANIL SHAH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 PARKVIEW CIR
WAYNE PA
19087-4188
US

IV. Provider business mailing address

94 PARKVIEW CIR
WAYNE PA
19087-4188
US

V. Phone/Fax

Practice location:
  • Phone: 201-248-1286
  • Fax:
Mailing address:
  • Phone: 201-248-1286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02526900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10984
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS039945
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: