Provider Demographics
NPI:1356564462
Name:SHAH, KISHORE M IX (DDS)
Entity type:Individual
Prefix:DR
First Name:KISHORE
Middle Name:M
Last Name:SHAH
Suffix:IX
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:KISHORE
Other - Middle Name:M
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:18 WHITEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-1137
Mailing Address - Country:US
Mailing Address - Phone:914-592-6694
Mailing Address - Fax:
Practice Address - Street 1:321 WYCKOFF AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2753
Practice Address - Country:US
Practice Address - Phone:718-386-3288
Practice Address - Fax:718-386-3540
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0354891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00513864Medicaid