Provider Demographics
NPI:1063412054
Name:SHAH, JOLLY (DDS)
Entity type:Individual
Prefix:DR
First Name:JOLLY
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 E CAPITOL EXPY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-1561
Mailing Address - Country:US
Mailing Address - Phone:408-223-2500
Mailing Address - Fax:408-223-5525
Practice Address - Street 1:1761 E CAPITOL EXPY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1561
Practice Address - Country:US
Practice Address - Phone:408-223-2500
Practice Address - Fax:408-223-5525
Is Sole Proprietor?:No
Enumeration Date:2005-07-30
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA447751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92525-01Medicaid
CAB44775-01OtherALAMEDA ALLIANCE
CAB44775-01OtherSANTA CLARA HEALTHY KIDS