Provider Demographics
NPI:1396082228
Name:SHAH, BANSARI MODI (DDS)
Entity type:Individual
Prefix:DR
First Name:BANSARI
Middle Name:MODI
Last Name:SHAH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9654
Mailing Address - Country:US
Mailing Address - Phone:973-650-9527
Mailing Address - Fax:
Practice Address - Street 1:76 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-2430
Practice Address - Country:US
Practice Address - Phone:973-744-3127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102519200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist