Healthcare Provider Details

I. General information

NPI: 1255636718
Provider Name (Legal Business Name): EMERY DENTAL CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 S ELMHURST RD
MOUNT PROSPECT IL
60056-5805
US

IV. Provider business mailing address

2380 S ELMHURST RD
MOUNT PROSPECT IL
60056-5805
US

V. Phone/Fax

Practice location:
  • Phone: 847-228-5557
  • Fax: 847-228-6526
Mailing address:
  • Phone: 847-228-5557
  • Fax: 847-228-6526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019027741
License Number StateIL

VIII. Authorized Official

Name: DR. FAWAD J SHAH
Title or Position: OWNER
Credential: DMD
Phone: 847-228-5557