Provider Demographics
NPI:1487636908
Name:SHAH, PAYAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAYAL
Middle Name:
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 1:2596 HILLSBORO BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60503-6732
Mailing Address - Country:US
Mailing Address - Phone:630-692-1615
Mailing Address - Fax:
Practice Address - Street 1:3240 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3428
Practice Address - Country:US
Practice Address - Phone:708-788-6768
Practice Address - Fax:708-788-3666
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9179257Medicaid