Provider Demographics
NPI:1407846298
Name:SHAH, KALPANA TUSHAR (DMD)
Entity type:Individual
Prefix:DR
First Name:KALPANA
Middle Name:TUSHAR
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 1:1 MICHELE CT
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-4921
Mailing Address - Country:US
Mailing Address - Phone:815-609-7209
Mailing Address - Fax:
Practice Address - Street 1:2025 S CHICAGO ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436-3172
Practice Address - Country:US
Practice Address - Phone:815-727-5813
Practice Address - Fax:815-727-7260
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190257131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9176397Medicaid