Provider Demographics
NPI:1942736434
Name:KINNAR SHAH, DMD, PC
Entity Type:Organization
Organization Name:KINNAR SHAH, DMD, PC
Other - Org Name:SOUTHBRIDGE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KINNAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-385-1003
Mailing Address - Street 1:305 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-3726
Mailing Address - Country:US
Mailing Address - Phone:508-765-0880
Mailing Address - Fax:
Practice Address - Street 1:305 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-3726
Practice Address - Country:US
Practice Address - Phone:508-765-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN185621881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty