Healthcare Provider Details

I. General information

NPI: 1023170404
Provider Name (Legal Business Name): TINA A SHROFF DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E SIBLEY BLVD
DOLTON IL
60419-2836
US

IV. Provider business mailing address

1021 E SIBLEY BLVD
DOLTON IL
60419-2836
US

V. Phone/Fax

Practice location:
  • Phone: 708-849-9520
  • Fax: 908-849-9584
Mailing address:
  • Phone: 708-849-9520
  • Fax: 908-849-9584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019024341
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: