Provider Demographics
NPI:1215500251
Name:SHAH, DHARA H
Entity type:Individual
Prefix:
First Name:DHARA
Middle Name:H
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10608 PLUCHEA CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78733-5721
Mailing Address - Country:US
Mailing Address - Phone:737-206-1611
Mailing Address - Fax:
Practice Address - Street 1:9511 N LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-4107
Practice Address - Country:US
Practice Address - Phone:737-401-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1066171223G0001X
TX383761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice