Provider Demographics
NPI:1912103888
Name:SHAH, ASHMITA JAYARAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:ASHMITA
Middle Name:JAYARAM
Last Name:SHAH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ASHMITA
Other - Middle Name:
Other - Last Name:JAYARAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1180 RESURGENCE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7210
Mailing Address - Country:US
Mailing Address - Phone:706-549-8737
Mailing Address - Fax:
Practice Address - Street 1:1180 RESURGENCE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7210
Practice Address - Country:US
Practice Address - Phone:706-549-8737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist