Provider Demographics
NPI:1467604363
Name:SHAH, JESAL VIRENDRA (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:JESAL
Middle Name:VIRENDRA
Last Name:SHAH
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1565
Mailing Address - Country:US
Mailing Address - Phone:212-567-5536
Mailing Address - Fax:212-202-6447
Practice Address - Street 1:3915 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1565
Practice Address - Country:US
Practice Address - Phone:212-567-5536
Practice Address - Fax:212-202-6447
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052986122300000X
NY052986-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist