Provider Demographics
NPI:1386953719
Name:SHAH, MITAL ANKIT
Entity type:Individual
Prefix:DR
First Name:MITAL
Middle Name:ANKIT
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761ST TANK BATTALLION AVE
Mailing Address - Street 2:BUILDING#330
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-285-2014
Mailing Address - Fax:254-285-2182
Practice Address - Street 1:761ST TANK BATTALLION AVE
Practice Address - Street 2:BUILDING#330
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-285-2014
Practice Address - Fax:254-285-2182
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX256131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice