Provider Demographics
NPI:1629702899
Name:GOKHALE, SHAMI
Entity Type:Individual
Prefix:
First Name:SHAMI
Middle Name:
Last Name:GOKHALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 CEDAR PLACE CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3312
Mailing Address - Country:US
Mailing Address - Phone:408-669-7959
Mailing Address - Fax:
Practice Address - Street 1:4323 ATL HIGHWAY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052
Practice Address - Country:US
Practice Address - Phone:678-367-4615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1228351223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223G0001XDental ProvidersDentistGeneral Practice