=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073908638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVAIT V. SHAH, DMD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2015
-----------------------------------------------------
Last Update Date | 03/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6629 HUNTSHIRE DR
-----------------------------------------------------
City | ELKRIDGE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21075-6188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-380-9603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6629 HUNTSHIRE DR
-----------------------------------------------------
City | ELKRIDGE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21075-6188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER/ DENTIST
-----------------------------------------------------
Name | DR. ADVAIT SHAH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-380-9603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 15215
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------