Basic Information
| Provider Information | |||||||||
| NPI: | 1558988329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUTHIRIKKULAM | ||||||||
| FirstName: | SHAHANA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 260 PITTSFIELD RD UNIT F5 | ||||||||
| Address2: | |||||||||
| City: | LENOX | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012402139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133580611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 510 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012015493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472781 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2020 | ||||||||
| LastUpdateDate: | 06/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DL14450 | MA | Y | Dental Providers | Dentist |
No ID Information.