Provider Demographics
NPI:1750461737
Name:FADAVI, SHAHRBANOO (DDS,MS)
Entity Type:Individual
Prefix:
First Name:SHAHRBANOO
Middle Name:
Last Name:FADAVI
Suffix:
Gender:F
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 MEADOW DR N
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4833 CHURCH ST
Practice Address - Street 2:801 S. POLINA
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1357
Practice Address - Country:US
Practice Address - Phone:847-673-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry