Provider Demographics
NPI:1811415284
Name:SHAH, SERENA MAYA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SERENA
Middle Name:MAYA
Last Name:SHAH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 N DESPLAINES ST APT 505
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2331
Mailing Address - Country:US
Mailing Address - Phone:415-990-3237
Mailing Address - Fax:
Practice Address - Street 1:5549 S CORNELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1914
Practice Address - Country:US
Practice Address - Phone:773-684-5702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0313641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice