Provider Demographics
NPI:1700239464
Name:RAOOF, SHOHREH
Entity Type:Individual
Prefix:
First Name:SHOHREH
Middle Name:
Last Name:RAOOF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5539 N MONITOR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1237
Mailing Address - Country:US
Mailing Address - Phone:773-417-9966
Mailing Address - Fax:
Practice Address - Street 1:5539 N MONITOR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1237
Practice Address - Country:US
Practice Address - Phone:773-417-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030789122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist