Provider Demographics
NPI:1710377494
Name:DR SRUJAL H SHAH DDS INC
Entity Type:Organization
Organization Name:DR SRUJAL H SHAH DDS INC
Other - Org Name:SPARK SLEEP SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRUJAL
Authorized Official - Middle Name:HARSHAD
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-490-0182
Mailing Address - Street 1:6120 HELLYER AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-1066
Mailing Address - Country:US
Mailing Address - Phone:408-490-0182
Mailing Address - Fax:408-624-4545
Practice Address - Street 1:4340 SCOTTS VALLEY DR STE H
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4541
Practice Address - Country:US
Practice Address - Phone:408-490-0182
Practice Address - Fax:408-624-4545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58754122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6459840001Medicare NSC