Provider Demographics
NPI:1144787367
Name:KULOBA, SHANICE SHAMELA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANICE
Middle Name:SHAMELA
Last Name:KULOBA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 SUMMIT ST STE 105
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-3861
Mailing Address - Country:US
Mailing Address - Phone:847-780-9407
Mailing Address - Fax:
Practice Address - Street 1:431 SUMMIT ST STE 105
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-3861
Practice Address - Country:US
Practice Address - Phone:847-780-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-24
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190325511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice