Provider Demographics
NPI:1558830794
Name:MOHAN, SIDHARTH (MSD, BDS, BS)
Entity Type:Individual
Prefix:
First Name:SIDHARTH
Middle Name:
Last Name:MOHAN
Suffix:
Gender:M
Credentials:MSD, BDS, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 BROOKFOREST AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-8807
Mailing Address - Country:US
Mailing Address - Phone:864-940-8987
Mailing Address - Fax:
Practice Address - Street 1:964 BROOKFOREST AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-8807
Practice Address - Country:US
Practice Address - Phone:815-254-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031930122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist