=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588184709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SNEHA SHAH DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2017
-----------------------------------------------------
Last Update Date | 08/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15148 N DALE MABRY HWY
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33618-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-855-3510
-----------------------------------------------------
Fax | 813-265-8126
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 GARNET TER
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-533-0058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 22DI02714300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN27406
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------