Basic Information
| Provider Information | |||||||||
| NPI: | 1386953719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | MITAL | ||||||||
| MiddleName: | ANKIT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 761ST TANK BATTALLION AVE | ||||||||
| Address2: | BUILDING#330 | ||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542852014 | ||||||||
| FaxNumber: | 2542852182 | ||||||||
| Practice Location | |||||||||
| Address1: | 761ST TANK BATTALLION AVE | ||||||||
| Address2: | BUILDING#330 | ||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542852014 | ||||||||
| FaxNumber: | 2542852182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 25613 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.