Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 12417 | GA |
NPI | 1003980020 |
---|---|
Provider Name | Bhavik P Shah |
First Address | Fayetteville, GA 30214-4572 |
Second Address | Fayetteville, GA 30214-4572 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/11/2006 |
Last Update Date | 04/04/2017 |