Provider Demographics
NPI:1972918308
Name:BANSAL, SHOBHIT
Entity Type:Individual
Prefix:DR
First Name:SHOBHIT
Middle Name:
Last Name:BANSAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12471 GLAZIER ST
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-6072
Mailing Address - Country:US
Mailing Address - Phone:646-703-3924
Mailing Address - Fax:
Practice Address - Street 1:9920 N ROUTE 47
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142
Practice Address - Country:US
Practice Address - Phone:646-703-3924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001717-151223G0001X
IL190304351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice