Provider Demographics
NPI:1720334956
Name:SHUKLA, JANAKI VIMLESH (DMD)
Entity Type:Individual
Prefix:
First Name:JANAKI
Middle Name:VIMLESH
Last Name:SHUKLA
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 1:70 W BURTON PL
Mailing Address - Street 2:APT. 2007
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 UNION ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1207
Practice Address - Country:US
Practice Address - Phone:508-481-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18563981223G0001X
IL0190305501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice