Healthcare Provider Details

I. General information

NPI: 1598466146
Provider Name (Legal Business Name): SHRUTI GOYAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5402 WALZEM RD
WINDCREST TX
78218-2125
US

IV. Provider business mailing address

PO BOX 660682
DALLAS TX
75266-0682
US

V. Phone/Fax

Practice location:
  • Phone: 210-599-4444
  • Fax:
Mailing address:
  • Phone: 972-444-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number39531
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: