Provider Demographics
NPI:1366556037
Name:SHAH, TIKA (DMD)
Entity type:Individual
Prefix:
First Name:TIKA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:TIKA
Other - Middle Name:TIKA
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:5701 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112
Mailing Address - Country:US
Mailing Address - Phone:314-367-7848
Mailing Address - Fax:314-367-2985
Practice Address - Street 1:11642 WEST FLORISSANT
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63033
Practice Address - Country:US
Practice Address - Phone:314-838-8220
Practice Address - Fax:314-838-8091
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000159262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO409036811Medicaid
MOV01590Medicare UPIN
MO000025690Medicare PIN