Provider Demographics
NPI:1679904171
Name:KALPANA T. SHAH, DMD, PC
Entity Type:Organization
Organization Name:KALPANA T. SHAH, DMD, PC
Other - Org Name:PRIMARY FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KALPANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-727-5813
Mailing Address - Street 1:1000 W JEFFERSON ST
Mailing Address - Street 2:101
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6812
Mailing Address - Country:US
Mailing Address - Phone:815-727-5813
Mailing Address - Fax:779-205-3423
Practice Address - Street 1:1000 W JEFFERSON ST
Practice Address - Street 2:101
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6812
Practice Address - Country:US
Practice Address - Phone:815-727-5813
Practice Address - Fax:779-205-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025713122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty