Provider Demographics
NPI:1730496407
Name:SHAH, POONAM U (DDS)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:U
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 1:309 47TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1111
Mailing Address - Country:US
Mailing Address - Phone:718-492-2234
Mailing Address - Fax:
Practice Address - Street 1:309 47TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1111
Practice Address - Country:US
Practice Address - Phone:718-492-2234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0552491223P0221X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry