Healthcare Provider Details

I. General information

NPI: 1407332240
Provider Name (Legal Business Name): SHIVAM YOGESH MEHTA BDS, MDS, MDENTSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N COLEMAN ST STE 110
PROSPER TX
75078-2305
US

IV. Provider business mailing address

821 N COLEMAN ST STE 110
PROSPER TX
75078-2305
US

V. Phone/Fax

Practice location:
  • Phone: 972-347-1700
  • Fax:
Mailing address:
  • Phone: 972-347-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number38698
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number38698
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: