Provider Demographics
NPI:1164803235
Name:JYOTI R. SHAH, DDS INC
Entity Type:Organization
Organization Name:JYOTI R. SHAH, DDS INC
Other - Org Name:THE SMILE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JYOTI
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-915-0787
Mailing Address - Street 1:7526 E 82ND ST STE 110
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1462
Mailing Address - Country:US
Mailing Address - Phone:317-915-0787
Mailing Address - Fax:866-941-4941
Practice Address - Street 1:7526 E 82ND ST STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1462
Practice Address - Country:US
Practice Address - Phone:317-915-0787
Practice Address - Fax:866-941-4941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010068261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200206200AMedicaid