Provider Demographics
NPI:1922139641
Name:K J SHAH DDS, INC.
Entity Type:Organization
Organization Name:K J SHAH DDS, INC.
Other - Org Name:LANDMARK FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-815-4356
Mailing Address - Street 1:521 W CHANNEL ISLANDS BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-2132
Mailing Address - Country:US
Mailing Address - Phone:805-815-4356
Mailing Address - Fax:
Practice Address - Street 1:521 W CHANNEL ISLANDS BLVD STE 8
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041-2132
Practice Address - Country:US
Practice Address - Phone:805-815-4356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty