Provider Demographics
NPI:1215118591
Name:SHASTRI, TEJAL VINOD (DDS)
Entity type:Individual
Prefix:DR
First Name:TEJAL
Middle Name:VINOD
Last Name:SHASTRI
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 1:176 KINGSBERRY DR
Mailing Address - Street 2:APT. A
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-2220
Mailing Address - Country:US
Mailing Address - Phone:414-803-0020
Mailing Address - Fax:
Practice Address - Street 1:625 ELMWOOD AVE
Practice Address - Street 2:BOX 683
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2913
Practice Address - Country:US
Practice Address - Phone:585-275-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053740122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist