Provider Demographics
NPI:1760856041
Name:SHAH, MEHUL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MEHUL
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 PAOLI PIKE
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1831
Mailing Address - Country:US
Mailing Address - Phone:732-742-0917
Mailing Address - Fax:
Practice Address - Street 1:72 PAOLI PIKE
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1831
Practice Address - Country:US
Practice Address - Phone:610-647-1666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02609900122300000X
MADN1857184122300000X
PADS040489122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110114422AMedicaid