Provider Demographics
NPI:1508120072
Name:SHAH, JAY A (DMD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:A
Last Name:SHAH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BRICKLIN CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-1558
Mailing Address - Country:US
Mailing Address - Phone:904-887-9640
Mailing Address - Fax:
Practice Address - Street 1:3363 BATTLEGROUND AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2401
Practice Address - Country:US
Practice Address - Phone:336-933-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC112571223G0001X
CA61442122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist