Provider Demographics
NPI:1609339555
Name:SHAH, RAVI GAURANG (DMD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:GAURANG
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 1:171 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-1354
Mailing Address - Country:US
Mailing Address - Phone:732-318-9820
Mailing Address - Fax:
Practice Address - Street 1:171 LAKE AVE
Practice Address - Street 2:
Practice Address - City:COLONIA
Practice Address - State:NJ
Practice Address - Zip Code:07067-1354
Practice Address - Country:US
Practice Address - Phone:732-318-9820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI027595001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program