MEDICARE: A.S.SHAH,DMD, INC.

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	122300000X	Dentist	53672	CA

General Provider Information

NPI Number	:	1508268749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A.S.SHAH,DMD, INC.

Provider Business Mailing Address
First Line	:	2641 HAMNER AVE
Second Line	:	SUITE # 101
City	:	NORCO
State	:	CA
Zip	:	92860-3636
Country	:	US
Telephone Number	:	951-739-7770
Fax Number	:

Provider Business Practice Location Address
First Line	:	2641 HAMNER AVE
Second Line	:	SUITE 101
City	:	NORCO
State	:	CA
Zip	:	92860-3636
Country	:	US
Telephone Number	:	951-730-7770
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AMI SHAH
Credential	:	DMD
Telephone Number	:	858-201-0044

Provider Enumeration Date	:	09/18/2014
Last Update Date	:	09/18/2014

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