Provider Demographics
NPI:1619226016
Name:SHAH, ANAND (DMD)
Entity Type:Individual
Prefix:
First Name:ANAND
Middle Name:
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 1:2575 W NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3701
Mailing Address - Country:US
Mailing Address - Phone:321-914-0929
Mailing Address - Fax:
Practice Address - Street 1:2575 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3701
Practice Address - Country:US
Practice Address - Phone:321-914-0929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN199031223G0001X
FLDN 19903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice