=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053005678
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADRIENNE ANSON SHAH DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2023
-----------------------------------------------------
Last Update Date | 09/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43025 W 12 MILE RD
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48377-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-478-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 163 W KENILWORTH AVE
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48067-3262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-843-1990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 2901601999
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------