Healthcare Provider Details

I. General information

NPI: 1336808641
Provider Name (Legal Business Name): SHIVANIBEN PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2537 W NORTH AVE
MELROSE PARK IL
60160-1121
US

IV. Provider business mailing address

1200 S LESLIE LN
DES PLAINES IL
60018-5535
US

V. Phone/Fax

Practice location:
  • Phone: 224-400-1706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033672
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033672
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: