Provider Demographics
NPI:1649056375
Name:SHAH, MANUSH (DMD)
Entity type:Individual
Prefix:
First Name:MANUSH
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 GORMAN ST
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:470 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2103
Practice Address - Country:US
Practice Address - Phone:203-440-4199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT139001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty