Provider Demographics
NPI:1700476371
Name:SHAH, PRIYAL
Entity type:Individual
Prefix:
First Name:PRIYAL
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 1:45 MOODY ST UNIT 220
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5373
Mailing Address - Country:US
Mailing Address - Phone:617-637-6748
Mailing Address - Fax:
Practice Address - Street 1:1201 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01850-1293
Practice Address - Country:US
Practice Address - Phone:978-455-7056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADM18588961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice