Provider Demographics
NPI:1740776129
Name:ANKOLA, SHAAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHAAN
Middle Name:
Last Name:ANKOLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15551 DEWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-7719
Mailing Address - Country:US
Mailing Address - Phone:708-745-2758
Mailing Address - Fax:
Practice Address - Street 1:5917 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4515
Practice Address - Country:US
Practice Address - Phone:773-735-8353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist