Provider Demographics
NPI:1164551867
Name:SHAH, MOONI DILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOONI
Middle Name:DILIP
Last Name:SHAH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 MOUNT VERNON WAY
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-6421
Mailing Address - Country:US
Mailing Address - Phone:909-260-4900
Mailing Address - Fax:
Practice Address - Street 1:1013 W UNIVERSITY AVE STE 345
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-5345
Practice Address - Country:US
Practice Address - Phone:512-843-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37201122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist