Provider Demographics
NPI:1912139338
Name:SHIVAKUMAR, PREETI A (DDS)
Entity Type:Individual
Prefix:DR
First Name:PREETI
Middle Name:A
Last Name:SHIVAKUMAR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6914
Mailing Address - Country:US
Mailing Address - Phone:312-274-0308
Mailing Address - Fax:312-944-9499
Practice Address - Street 1:2240 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2411
Practice Address - Country:US
Practice Address - Phone:708-656-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028058122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist