Provider Demographics
NPI:1346807781
Name:SHAIK, IRFAN
Entity type:Individual
Prefix:
First Name:IRFAN
Middle Name:
Last Name:SHAIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10607 S HARLEM AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-1651
Mailing Address - Country:US
Mailing Address - Phone:708-361-0900
Mailing Address - Fax:
Practice Address - Street 1:10607 S HARLEM AVE STE B
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482-1651
Practice Address - Country:US
Practice Address - Phone:708-361-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033382122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty