=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962969022
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHILP DALAL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2019
-----------------------------------------------------
Last Update Date | 08/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 269 STATE ROUTE 18 S STE B
-----------------------------------------------------
City | EAST BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08816-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-955-0709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1631 PATERSON PLANK RD APT 312
-----------------------------------------------------
City | SECAUCUS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07094-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02805900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------