Provider Demographics
NPI:1043212582
Name:SHAH, MAMTA M (DDS)
Entity Type:Individual
Prefix:
First Name:MAMTA
Middle Name:M
Last Name:SHAH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CENTENNIAL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-4152
Mailing Address - Country:US
Mailing Address - Phone:732-562-1111
Mailing Address - Fax:
Practice Address - Street 1:1100 CENTENNIAL AVE
Practice Address - Street 2:SUITE# 101
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-4152
Practice Address - Country:US
Practice Address - Phone:732-562-1111
Practice Address - Fax:732-562-9666
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI021234001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice