Provider Demographics
NPI:1477122919
Name:SHAH, DHARA (DMD)
Entity Type:Individual
Prefix:
First Name:DHARA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
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:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-2101
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-757-8161
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-19
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034239122300000X, 1223G0001X
MI29016009081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Multi-Specialty