Provider Demographics
NPI:1912323098
Name:SHAH, AMIE
Entity Type:Individual
Prefix:
First Name:AMIE
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 1:140 ADDIS DR
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18966-1170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 MAIN ST STE 315-I
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1524
Practice Address - Country:US
Practice Address - Phone:267-210-1847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058278122300000X, 1223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program