Provider Demographics
NPI:1003224056
Name:SHASTRI, SHAMIK MAHENDRA (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:SHAMIK
Middle Name:MAHENDRA
Last Name:SHASTRI
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 VISTA COURT DR APT 2122
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-8393
Mailing Address - Country:US
Mailing Address - Phone:916-533-1715
Mailing Address - Fax:
Practice Address - Street 1:5851 LONG PRAIRIE RD STE 101
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-5636
Practice Address - Country:US
Practice Address - Phone:972-539-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63664122300000X
TX636641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist