Provider Demographics
NPI:1871091645
Name:SAMIR SHAH DDS INC
Entity type:Organization
Organization Name:SAMIR SHAH DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-746-0444
Mailing Address - Street 1:469 W BASE LINE RD
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:469 W BASE LINE RD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-3379
Practice Address - Country:US
Practice Address - Phone:909-746-0444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA532721223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty