Healthcare Provider Details

I. General information

NPI: 1144059239
Provider Name (Legal Business Name): DHWANIL SHAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MAIN ST
SAVANNA IL
61074-1535
US

IV. Provider business mailing address

17-148 EDGEWATER DR
LANARK IL
61046-9366
US

V. Phone/Fax

Practice location:
  • Phone: 815-367-6430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037272
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: