Provider Demographics
NPI:1831304823
Name:SHAH, JATIN PRABHUDAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JATIN
Middle Name:PRABHUDAS
Last Name:SHAH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 S DIAMOND BAR BLVD APT 108
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2919
Mailing Address - Country:US
Mailing Address - Phone:909-860-2511
Mailing Address - Fax:
Practice Address - Street 1:2242 S MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-6132
Practice Address - Country:US
Practice Address - Phone:909-391-1549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist