Provider Demographics
NPI:1922186162
Name:SHAH, JITENDRA S (DDS)
Entity Type:Individual
Prefix:MR
First Name:JITENDRA
Middle Name:S
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 1:8613 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-2043
Mailing Address - Country:US
Mailing Address - Phone:718-847-3300
Mailing Address - Fax:718-850-8865
Practice Address - Street 1:10561 MERRITT ST
Practice Address - Street 2:
Practice Address - City:CASTROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95012-3310
Practice Address - Country:US
Practice Address - Phone:831-633-1514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY356731223G0001X
CA1000461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00572523Medicaid
NY00572523Medicaid