Provider Demographics
NPI:1497759179
Name:AMIRSOLTANI, SHAFA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAFA
Middle Name:
Last Name:AMIRSOLTANI
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 1:7234 W NORTH AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707
Mailing Address - Country:US
Mailing Address - Phone:708-383-3377
Mailing Address - Fax:708-383-3779
Practice Address - Street 1:7234 W NORTH AVE
Practice Address - Street 2:STE 202
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707
Practice Address - Country:US
Practice Address - Phone:708-383-3377
Practice Address - Fax:708-383-3779
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023196122300000X
IL019-0231961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist