Provider Demographics
NPI:1770229007
Name:BUTALA, SHIVANI V (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHIVANI
Middle Name:V
Last Name:BUTALA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHIVANI
Other - Middle Name:MANOJKUMAR
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:16601 PALM ROYAL DR APT 1429
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2687
Mailing Address - Country:US
Mailing Address - Phone:973-954-1336
Mailing Address - Fax:
Practice Address - Street 1:2119 W BRANDON BLVD STE F
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4731
Practice Address - Country:US
Practice Address - Phone:813-662-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN269481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice