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General NPI Number Information
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NPI Number | 1396082228
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Entity Type | Individual
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Provider Name | BANSARI MODI SHAH DDS
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Gender | Female
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Dates
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Enumeration Date | 01/11/2013
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Last Update Date | 08/19/2022
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Provider Practice Location Address
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Address Line | 76 BELLEVUE AVE
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City | MONTCLAIR
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State | NJ
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Zip | 07043-2430
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Country | US
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Telephone | 973-744-3127
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Fax |
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Provider Business Mailing Address
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Address Line | 98 WINDSOR DR
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City | PINE BROOK
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State | NJ
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Zip | 07058-9654
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Country | US
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Telephone | 973-650-9527
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22D102519200
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License Number State | NJ
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