Provider Demographics
NPI:1780204719
Name:SHAH, SHIVANI VIJAY
Entity Type:Individual
Prefix:
First Name:SHIVANI
Middle Name:VIJAY
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 24TH ST APT 1006
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3996
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14610 45TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2234
Practice Address - Country:US
Practice Address - Phone:718-445-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2023-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0620311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice