Provider Demographics
NPI:1346239902
Name:ANANTHA, SHUBA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHUBA
Middle Name:
Last Name:ANANTHA
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 1:5445 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1725
Mailing Address - Country:US
Mailing Address - Phone:847-244-2775
Mailing Address - Fax:847-244-2777
Practice Address - Street 1:5445 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1725
Practice Address - Country:US
Practice Address - Phone:847-244-2775
Practice Address - Fax:847-244-2777
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190265651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice