Provider Demographics
NPI:1447404579
Name:SHAH, REENA P (DDS)
Entity Type:Individual
Prefix:DR
First Name:REENA
Middle Name:P
Last Name:SHAH
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 1:1360 N SANDBURG TER
Mailing Address - Street 2:102-C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2075
Mailing Address - Country:US
Mailing Address - Phone:312-664-6463
Mailing Address - Fax:
Practice Address - Street 1:1360 N SANDBURG TER
Practice Address - Street 2:102-C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2075
Practice Address - Country:US
Practice Address - Phone:312-664-6463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053702122300000X
IL019027040122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist