=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003505587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAHU DENTISTRY, PLLC DBA EXCEL DENTAL DEPOT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2023
-----------------------------------------------------
Last Update Date | 05/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3368 S LINDEN RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48507-3008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-387-9767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6415 MOONSTONE DR
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-7811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-387-9767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PURNA SHAH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 989-387-9767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------