Provider Demographics
NPI:1871645101
Name:SHAH, KISHORE (DDS)
Entity type:Individual
Prefix:
First Name:KISHORE
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21001 SHERMAN WAY STE 13
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-3680
Mailing Address - Country:US
Mailing Address - Phone:818-346-7032
Mailing Address - Fax:818-346-4835
Practice Address - Street 1:21001 SHERMAN WAY STE 13
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-3680
Practice Address - Country:US
Practice Address - Phone:818-346-7032
Practice Address - Fax:818-346-4835
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice