Provider Demographics
NPI:1083657746
Name:SHIRAH, JEFFREY W (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:W
Last Name:SHIRAH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 BURNET RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-2003
Mailing Address - Country:US
Mailing Address - Phone:512-458-5999
Mailing Address - Fax:
Practice Address - Street 1:5310 BURNET RD
Practice Address - Street 2:SUITE 108
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-2003
Practice Address - Country:US
Practice Address - Phone:512-458-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17289122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ970972Medicaid
V06412Medicare UPIN
8EB970Medicare PIN