MEDICARE: JESAL SHAH, DMD, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	052986	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366985491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESAL SHAH, DMD, P.C.

Provider Business Mailing Address
First Line	:	4609 5TH AVE
Second Line	:	2ND FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11220-1207
Country	:	US
Telephone Number	:	718-854-3191
Fax Number	:	718-909-1635

Provider Business Practice Location Address
First Line	:	4609 5TH AVE
Second Line	:	2ND FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11220-1207
Country	:	US
Telephone Number	:	718-854-3191
Fax Number	:	718-909-1635

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JESAL SHAH
Credential	:	DMD
Telephone Number	:	516-395-2659

Provider Enumeration Date	:	11/21/2016
Last Update Date	:	11/21/2016

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