Healthcare Provider Details

I. General information

NPI: 1265306336
Provider Name (Legal Business Name): SHIVANI NITIN SHAH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S RANDALL RD STE G
ELGIN IL
60123-4607
US

IV. Provider business mailing address

23578 N VALLEY RD
LAKE ZURICH IL
60047-8705
US

V. Phone/Fax

Practice location:
  • Phone: 224-629-4125
  • Fax:
Mailing address:
  • Phone: 224-595-1829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019037493
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: