Provider Demographics
NPI:1073900411
Name:NORTHWEST DENTIQ CENTER P.C.
Entity Type:Organization
Organization Name:NORTHWEST DENTIQ CENTER P.C.
Other - Org Name:PINGREE SMILE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KALPIT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-462-4330
Mailing Address - Street 1:2401 W. RT 20
Mailing Address - Street 2:STE 103
Mailing Address - City:PINGREE GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60140
Mailing Address - Country:US
Mailing Address - Phone:847-462-4330
Mailing Address - Fax:
Practice Address - Street 1:2401 W. RT 20
Practice Address - Street 2:STE 103
Practice Address - City:PINGREE GROVE
Practice Address - State:IL
Practice Address - Zip Code:60140
Practice Address - Country:US
Practice Address - Phone:847-462-4330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty