Provider Demographics
NPI:1104867431
Name:SHAH, BRIAN S (DDS, MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:SHAH
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 W WEBSTER AVE FRNT
Mailing Address - Street 2:CHICAGO SURGICAL ARTS
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3502
Mailing Address - Country:US
Mailing Address - Phone:872-829-3280
Mailing Address - Fax:872-829-3281
Practice Address - Street 1:1009 W WEBSTER AVE
Practice Address - Street 2:STORE FRONT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3502
Practice Address - Country:US
Practice Address - Phone:872-829-3280
Practice Address - Fax:872-829-3281
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0281911223S0112X
IL036.125106204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEV09978Medicare UPIN