Provider Demographics
NPI:1417299926
Name:PALOS ORTHODONTICS
Entity Type:Organization
Organization Name:PALOS ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEYUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-945-1455
Mailing Address - Street 1:10781 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-2313
Mailing Address - Country:US
Mailing Address - Phone:708-974-1155
Mailing Address - Fax:708-974-2966
Practice Address - Street 1:10781 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-2313
Practice Address - Country:US
Practice Address - Phone:708-974-1155
Practice Address - Fax:708-974-2966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0022321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty