MEDICARE: SHETH DENTAL ASSOC. P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	01921108	IL

General Provider Information

NPI Number	:	1003134990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHETH DENTAL ASSOC. P.C.

Provider Business Mailing Address
First Line	:	3705 E 106TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-6725
Country	:	US
Telephone Number	:	773-978-7773
Fax Number	:	773-978-0419

Provider Business Practice Location Address
First Line	:	3705 E 106TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-6725
Country	:	US
Telephone Number	:	773-978-7773
Fax Number	:	773-978-0419

Authorized Official
Title or Position	:	PRESIDENT/SEC
Name	:	DR. PRAMILA SHETH
Credential	:	DDS
Telephone Number	:	773-978-7773

Provider Enumeration Date	:	05/17/2010
Last Update Date	:	05/17/2010

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