Provider Demographics
NPI:1790462760
Name:SHAH, SUHRUD JITENDRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUHRUD
Middle Name:JITENDRA
Last Name:SHAH
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 1:5249 N MOBILE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1009
Mailing Address - Country:US
Mailing Address - Phone:773-456-7995
Mailing Address - Fax:
Practice Address - Street 1:5249 N MOBILE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1009
Practice Address - Country:US
Practice Address - Phone:773-456-7995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034413122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist