Provider Demographics
NPI:1194467639
Name:SHAH, SAMYAK SHASHIKANT
Entity Type:Individual
Prefix:
First Name:SAMYAK
Middle Name:SHASHIKANT
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-925-4031
Mailing Address - Fax:505-925-4030
Practice Address - Street 1:1790 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-1934
Practice Address - Country:US
Practice Address - Phone:303-659-1064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002056931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice