MEDICARE: PEQUANNOCK DENTAL, PC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1730546417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEQUANNOCK DENTAL, PC

Provider Business Mailing Address
First Line	:	157 NEWARK POMPTON TPKE
Second Line	:
City	:	PEQUANNOCK
State	:	NJ
Zip	:	07440-1300
Country	:	US
Telephone Number	:	973-696-4252
Fax Number	:	973-872-9018

Provider Business Practice Location Address
First Line	:	157 NEWARK POMPTON TPKE
Second Line	:
City	:	PEQUANNOCK
State	:	NJ
Zip	:	07440-1300
Country	:	US
Telephone Number	:	973-696-4252
Fax Number	:	973-872-9018

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHREYANS SHAH
Credential	:	DMD
Telephone Number	:	973-696-4252

Provider Enumeration Date	:	01/26/2016
Last Update Date	:	01/26/2016

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