Provider Demographics
NPI:1174541296
Name:SHAH, BHARAT R I (DDS)
Entity type:Individual
Prefix:DR
First Name:BHARAT
Middle Name:R
Last Name:SHAH
Suffix:I
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 1:3000 DUNN AVE STE 38
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6551
Mailing Address - Country:US
Mailing Address - Phone:904-768-3790
Mailing Address - Fax:904-768-7132
Practice Address - Street 1:3000 DUNN AVE STE 38
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6551
Practice Address - Country:US
Practice Address - Phone:904-768-3790
Practice Address - Fax:904-768-7132
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN116961223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071934000Medicaid