Provider Demographics
NPI:1174262562
Name:TAMRAKAR, SHRASTA TAYO (DMD)
Entity Type:Individual
Prefix:
First Name:SHRASTA
Middle Name:TAYO
Last Name:TAMRAKAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 W JEROME ST APT A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1542
Mailing Address - Country:US
Mailing Address - Phone:773-865-2643
Mailing Address - Fax:
Practice Address - Street 1:500 DAVIS ST STE 601
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4622
Practice Address - Country:US
Practice Address - Phone:847-492-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0336181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice