Provider Demographics
NPI:1639785850
Name:SHAH, ANSHUL MIKIN
Entity Type:Individual
Prefix:
First Name:ANSHUL MIKIN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11740 WILSHIRE BLVD # A1802
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6536
Mailing Address - Country:US
Mailing Address - Phone:013-567-1182
Mailing Address - Fax:
Practice Address - Street 1:6066 STRATHMOOR DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6633
Practice Address - Country:US
Practice Address - Phone:815-226-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty