Provider Demographics
NPI:1689820128
Name:BUTALA, SHAILESH MANHARLAL (DDS)
Entity Type:Individual
Prefix:
First Name:SHAILESH
Middle Name:MANHARLAL
Last Name:BUTALA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 E HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5601
Mailing Address - Country:US
Mailing Address - Phone:909-469-2230
Mailing Address - Fax:
Practice Address - Street 1:744 E HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5601
Practice Address - Country:US
Practice Address - Phone:909-469-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA42281OtherDENTICAL