Provider Demographics
NPI:1275617482
Name:SHETTY, GEETHA B (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEETHA
Middle Name:B
Last Name:SHETTY
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 1:8715 37TH AVE
Mailing Address - Street 2:PROFESSIONAL OFFICE A
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7701
Mailing Address - Country:US
Mailing Address - Phone:718-651-8488
Mailing Address - Fax:718-651-8402
Practice Address - Street 1:8715 37TH AVE
Practice Address - Street 2:PROFESSIONAL OFFICE A
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7701
Practice Address - Country:US
Practice Address - Phone:718-651-8488
Practice Address - Fax:718-651-8402
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0474371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02460873Medicaid