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General NPI Number Information
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NPI Number | 1164974853
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Entity Type | Organization
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Legal Business Name | MOHEGAN LAKE DENTAL PC
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Dates
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Enumeration Date | 10/27/2016
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 1719 E MAIN ST
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City | MOHEGAN LAKE
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State | NY
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Zip | 10547-1356
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Country | US
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Telephone | 914-528-2191
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Fax | 914-743-1579
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Provider Business Mailing Address
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Address Line | 1719 E MAIN ST
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City | MOHEGAN LAKE
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State | NY
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Zip | 10547-1356
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Country | US
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Telephone | 914-528-2191
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Fax | 914-743-1579
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. OJAS V. SHAH
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Credential | DDS
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Telephone | 914-310-1609
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 0556901
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License Number State | NY
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