Provider Demographics
NPI:1639788334
Name:SHAH, MARIYAM (DDS)
Entity Type:Individual
Prefix:
First Name:MARIYAM
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 NIGHTMUSE WAY
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-4800
Mailing Address - Country:US
Mailing Address - Phone:713-548-7184
Mailing Address - Fax:
Practice Address - Street 1:8111 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-5115
Practice Address - Country:US
Practice Address - Phone:804-918-9667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist