Provider Demographics
NPI:1538358759
Name:SHANTIKUMAR, MAYA
Entity type:Individual
Prefix:DR
First Name:MAYA
Middle Name:
Last Name:SHANTIKUMAR
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 1:1301 ORLEANS ST
Mailing Address - Street 2:APARTMENT 1609
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2907
Mailing Address - Country:US
Mailing Address - Phone:810-687-5040
Mailing Address - Fax:
Practice Address - Street 1:8326 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-1648
Practice Address - Country:US
Practice Address - Phone:810-687-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019717122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist