Provider Demographics
NPI:1376621599
Name:SHAH, DEVILA J (DDS FAGD)
Entity Type:Individual
Prefix:MRS
First Name:DEVILA
Middle Name:J
Last Name:SHAH
Suffix:
Gender:F
Credentials:DDS FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11624 CANDY ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:SANDIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131
Mailing Address - Country:US
Mailing Address - Phone:858-564-9400
Mailing Address - Fax:
Practice Address - Street 1:1279 E VISTA WAY
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-4039
Practice Address - Country:US
Practice Address - Phone:516-931-3615
Practice Address - Fax:516-931-3616
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38937-11223G0001X
CADDS624141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00865063Medicaid
NY113233013Medicare UPIN