Healthcare Provider Details

I. General information

NPI: 1538905120
Provider Name (Legal Business Name): SHWETA DEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N VETERANS PKWY
BLOOMINGTON IL
61704-2296
US

IV. Provider business mailing address

3010 RUDDER LN APT 112
BLOOMINGTON IL
61704-8780
US

V. Phone/Fax

Practice location:
  • Phone: 309-319-9577
  • Fax:
Mailing address:
  • Phone: 323-961-2735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.035444
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: