Provider Demographics
NPI:1669503397
Name:SHAH, KOSHA (DDS)
Entity Type:Individual
Prefix:
First Name:KOSHA
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 1:521 W CHANNEL ISLANDS BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-2132
Mailing Address - Country:US
Mailing Address - Phone:805-815-4356
Mailing Address - Fax:
Practice Address - Street 1:521 W CHANNEL ISLANDS BLVD STE 8
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041-2132
Practice Address - Country:US
Practice Address - Phone:805-815-4356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49804122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD49804OtherDENTI-CAL