Provider Demographics
NPI:1942789847
Name:KOTA, SHREYA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHREYA
Middle Name:
Last Name:KOTA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3652
Mailing Address - Country:US
Mailing Address - Phone:708-652-2468
Mailing Address - Fax:708-749-2429
Practice Address - Street 1:7001 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3652
Practice Address - Country:US
Practice Address - Phone:708-652-2468
Practice Address - Fax:708-749-2429
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019037411223G0001X
IL019.0317411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice