Provider Demographics
NPI:1427574805
Name:JOGANI, SHRUTI RAHIL
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:RAHIL
Last Name:JOGANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 N HARBOR DR APT 1706
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4501 S STATE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3758
Practice Address - Country:US
Practice Address - Phone:773-548-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031345122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist