Provider Demographics
NPI:1679735070
Name:SHAH, ANKUR (DMD)
Entity type:Individual
Prefix:DR
First Name:ANKUR
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W BRIAR PL UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4520
Mailing Address - Country:US
Mailing Address - Phone:847-800-3604
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:215-823-5800
Practice Address - Fax:215-823-5827
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027891122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist