Provider Demographics
NPI:1407332240
Name:MEHTA, SHIVAM YOGESH (BDS, MDS, MDENTSC)
Entity Type:Individual
Prefix:
First Name:SHIVAM
Middle Name:YOGESH
Last Name:MEHTA
Suffix:
Gender:M
Credentials:BDS, MDS, MDENTSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE CAROLYN PKWY APT 3027
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-4715
Mailing Address - Country:US
Mailing Address - Phone:773-231-3050
Mailing Address - Fax:
Practice Address - Street 1:3806 E BROAD ST STE 108
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5621
Practice Address - Country:US
Practice Address - Phone:773-231-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38698122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist