Provider Demographics
NPI:1740639772
Name:THOMAS, SHAWN (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE STE 1904
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3605
Mailing Address - Country:US
Mailing Address - Phone:312-236-8514
Mailing Address - Fax:312-372-1743
Practice Address - Street 1:30 N MICHIGAN AVE STE 1904
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602
Practice Address - Country:US
Practice Address - Phone:312-236-8514
Practice Address - Fax:312-372-1743
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210029521223P0300X
PADS040876122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist