Provider Demographics
NPI:1396363669
Name:SHUKLA, NISHA PARITOSH
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:PARITOSH
Last Name:SHUKLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 MARINA CT APT F
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1604
Mailing Address - Country:US
Mailing Address - Phone:650-495-6334
Mailing Address - Fax:
Practice Address - Street 1:1477 FITZGERALD DR STE 106
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2257
Practice Address - Country:US
Practice Address - Phone:650-495-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1050131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice