Healthcare Provider Details

I. General information

NPI: 1124800016
Provider Name (Legal Business Name): JILL JAGDISHKUMAR SHAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S 348TH ST STE 102
FEDERAL WAY WA
98003-7015
US

IV. Provider business mailing address

240 S 40TH ST OFFICE OF CLINICAL AFFAIRS-S6A EVANS
PHILADELPHIA PA
19104-6030
US

V. Phone/Fax

Practice location:
  • Phone: 253-927-5501
  • Fax:
Mailing address:
  • Phone: 215-573-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDENT.DE.70144337
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: