Provider Demographics
NPI:1306452289
Name:SHAH, SHIVANI R (DMD)
Entity type:Individual
Prefix:DR
First Name:SHIVANI
Middle Name:R
Last Name:SHAH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 NAPLES CT
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-8970
Mailing Address - Country:US
Mailing Address - Phone:630-415-4567
Mailing Address - Fax:
Practice Address - Street 1:1355 N GALENA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1009
Practice Address - Country:US
Practice Address - Phone:815-284-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190328991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice