=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366808479
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BHAVI SHAH DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2016
-----------------------------------------------------
Last Update Date | 01/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13300 SAN ANTONIO DR
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-2969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-863-9396
-----------------------------------------------------
Fax | 562-864-7436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13300 SAN ANTONIO DR
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-2969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-863-9396
-----------------------------------------------------
Fax | 562-864-7436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BHAVI SHAH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 714-467-8587
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D55565
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------