Provider Demographics
NPI:1952610008
Name:NISTAR, SHAHNAAZ (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAHNAAZ
Middle Name:
Last Name:NISTAR
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 1:45 OWENCROFT RD # 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4723
Mailing Address - Country:US
Mailing Address - Phone:917-892-3625
Mailing Address - Fax:
Practice Address - Street 1:48 AUBURN ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2438
Practice Address - Country:US
Practice Address - Phone:508-832-6278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24242122300000X
MADN18574561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1952610008Medicaid