Basic Information
| Provider Information | |||||||||
| NPI: | 1033750070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | KAUSHAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608858131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647769547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448538937 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2019 | ||||||||
| LastUpdateDate: | 09/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN1858506 | MA | N | Dental Providers | Dentist | 122300000X | 2020030132 | MO | Y | Dental Providers | Dentist |
No ID Information.