Provider Demographics
NPI:1225655939
Name:SHAH, AVISHA RAKESH (DDS)
Entity Type:Individual
Prefix:
First Name:AVISHA
Middle Name:RAKESH
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 1:11841 TROPHY CLUB DR APT 207-4
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1472
Mailing Address - Country:US
Mailing Address - Phone:310-402-3371
Mailing Address - Fax:
Practice Address - Street 1:3712 OLD FOREST RD STE 100
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-6963
Practice Address - Country:US
Practice Address - Phone:434-385-0273
Practice Address - Fax:434-385-6269
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014168491223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics