Provider Demographics
NPI:1275023962
Name:SHAH, KANCHI B
Entity Type:Individual
Prefix:
First Name:KANCHI
Middle Name:B
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 KING WAY
Mailing Address - Street 2:
Mailing Address - City:BREINIGSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18031-1483
Mailing Address - Country:US
Mailing Address - Phone:440-864-1786
Mailing Address - Fax:
Practice Address - Street 1:1425 PENN AVE
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-2133
Practice Address - Country:US
Practice Address - Phone:610-372-6693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0433231223X0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program