Provider Demographics
NPI:1679912711
Name:SHEHATA, EHAB A (DDS,MBCHB,PHD,MSC/GS)
Entity type:Individual
Prefix:DR
First Name:EHAB
Middle Name:A
Last Name:SHEHATA
Suffix:
Gender:M
Credentials:DDS,MBCHB,PHD,MSC/GS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 W BALTIMORE ST STE 5201
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1510
Mailing Address - Country:US
Mailing Address - Phone:410-706-7060
Mailing Address - Fax:410-706-0891
Practice Address - Street 1:650 W BALTIMORE ST STE 5201
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1510
Practice Address - Country:US
Practice Address - Phone:410-706-7060
Practice Address - Fax:410-706-0891
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLL870122300000X, 1223P0106X, 1223S0112X
KYFL047204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100372790Medicaid
KY7100257170Medicaid