Provider Demographics
NPI:1932360401
Name:HARIRI, SHAHRAM (DDS)
Entity Type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:HARIRI
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 1:7120 FOREST GLEN DR
Mailing Address - Street 2:APARTMENT J
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8034
Mailing Address - Country:US
Mailing Address - Phone:248-224-5158
Mailing Address - Fax:
Practice Address - Street 1:430 W ERIE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-6914
Practice Address - Country:US
Practice Address - Phone:920-838-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027705122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019027705Medicaid