Provider Demographics
NPI:1922271550
Name:DESAI, SHYAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHYAM
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3741 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3609
Mailing Address - Country:US
Mailing Address - Phone:203-374-1911
Mailing Address - Fax:
Practice Address - Street 1:3741 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3609
Practice Address - Country:US
Practice Address - Phone:203-374-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0374251223X0400X
CT0098021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics