Provider Demographics
NPI:1356793814
Name:SHAH, BINITA
Entity type:Individual
Prefix:
First Name:BINITA
Middle Name:
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 1:201 E LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:93286-1301
Mailing Address - Country:US
Mailing Address - Phone:954-292-6836
Mailing Address - Fax:
Practice Address - Street 1:201 E LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:WOODLAKE
Practice Address - State:CA
Practice Address - Zip Code:93286-1301
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32612122300000X
CT11703122300000X
390200000X
CA1017061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program