Provider Demographics
NPI:1417643255
Name:SHAH, PARTH
Entity Type:Individual
Prefix:
First Name:PARTH
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9345 KOSTNER AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1325
Mailing Address - Country:US
Mailing Address - Phone:224-595-1252
Mailing Address - Fax:
Practice Address - Street 1:1950 W POLK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-0395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.034197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program