Provider Demographics
NPI:1992108013
Name:SHAH, NIDHI (DDS,MDS)
Entity type:Individual
Prefix:
First Name:NIDHI
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DDS,MDS
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2024 N RACINE AVE APT A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4067
Mailing Address - Country:US
Mailing Address - Phone:631-353-9404
Mailing Address - Fax:
Practice Address - Street 1:6800 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-3493
Practice Address - Country:US
Practice Address - Phone:630-969-5350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032810122300000X
IL021.0030601223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist