Provider Demographics
NPI:1053856260
Name:VENUGOPAL, SHWETA
Entity Type:Individual
Prefix:
First Name:SHWETA
Middle Name:
Last Name:VENUGOPAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E ROLLINS RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-2244
Mailing Address - Country:US
Mailing Address - Phone:224-757-0050
Mailing Address - Fax:847-548-1637
Practice Address - Street 1:825 E ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-2244
Practice Address - Country:US
Practice Address - Phone:224-757-0050
Practice Address - Fax:847-548-1637
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-23
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030978122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist