Provider Demographics
NPI:1427428374
Name:ASHAMALLA, SHADY (DDS)
Entity type:Individual
Prefix:
First Name:SHADY
Middle Name:
Last Name:ASHAMALLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 S WASHINGTON AVE # 32780
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7319
Mailing Address - Country:US
Mailing Address - Phone:602-481-0153
Mailing Address - Fax:
Practice Address - Street 1:3245 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3004
Practice Address - Country:US
Practice Address - Phone:321-269-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10238122300000X
FL24595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist