Provider Demographics
NPI:1356506364
Name:SHAH, FAWAD J (DMD)
Entity Type:Individual
Prefix:DR
First Name:FAWAD
Middle Name:J
Last Name:SHAH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 S ELMHURST RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-5805
Mailing Address - Country:US
Mailing Address - Phone:847-493-7392
Mailing Address - Fax:847-627-4178
Practice Address - Street 1:2380 S ELMHURST RD
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-5805
Practice Address - Country:US
Practice Address - Phone:847-493-7392
Practice Address - Fax:847-627-4178
Is Sole Proprietor?:No
Enumeration Date:2008-07-20
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027741122300000X, 1223G0001X
AZD79331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist