Healthcare Provider Details

I. General information

NPI: 1457433765
Provider Name (Legal Business Name): NAWAL F SHAH D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1593 PUCKER ST
STOWE VT
05672-4579
US

IV. Provider business mailing address

1593 PUCKER ST
STOWE VT
05672-4579
US

V. Phone/Fax

Practice location:
  • Phone: 802-253-4157
  • Fax: 802-253-7025
Mailing address:
  • Phone: 802-253-4157
  • Fax: 802-253-7025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2205
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: