Provider Demographics
NPI:1265041800
Name:SHAH, BRENDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:
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 1:4136 E JOPPA RD STE F
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-2286
Mailing Address - Country:US
Mailing Address - Phone:410-256-2930
Mailing Address - Fax:
Practice Address - Street 1:4136 E JOPPA RD STE F
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-2286
Practice Address - Country:US
Practice Address - Phone:410-256-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16944122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist