Provider Demographics
NPI:1861621328
Name:SHAH, KOSHA K (DDS)
Entity type:Individual
Prefix:
First Name:KOSHA
Middle Name:K
Last Name:SHAH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 GRACE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-7415
Mailing Address - Country:US
Mailing Address - Phone:650-288-8453
Mailing Address - Fax:
Practice Address - Street 1:150 SOUTHFIELD AVE
Practice Address - Street 2:2203
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-7756
Practice Address - Country:US
Practice Address - Phone:650-288-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice