Provider Demographics
NPI:1588040976
Name:PHOENIX, SHIMA (DMD)
Entity Type:Individual
Prefix:
First Name:SHIMA
Middle Name:
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SHIMA
Other - Middle Name:
Other - Last Name:PHOENIX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4201 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2282
Mailing Address - Country:US
Mailing Address - Phone:618-241-0997
Mailing Address - Fax:
Practice Address - Street 1:4201 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2282
Practice Address - Country:US
Practice Address - Phone:618-241-0997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist