MEDICARE: DR. SHIVANI CHETAN DESAI DMD

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	019029949	IL

General Provider Information

NPI Number	:	1184032666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHIVANI CHETAN DESAI DMD

Provider Business Mailing Address
First Line	:	1904 WAKEFIELD LN
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-9196
Country	:	US
Telephone Number	:	309-287-4952
Fax Number	:

Provider Business Practice Location Address
First Line	:	1904 WAKEFIELD LN
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-9196
Country	:	US
Telephone Number	:	309-287-4952
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2014
Last Update Date	:	07/28/2014

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