Healthcare Provider Details

I. General information

NPI: 1659930360
Provider Name (Legal Business Name): SHRUTI THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 N UNIVERSITY AVE
ANN ARBOR MI
48109-1078
US

IV. Provider business mailing address

1050 W MONROE ST UNIT 320
CHICAGO IL
60607-3705
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-6933
  • Fax:
Mailing address:
  • Phone: 248-345-4276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.032121
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601579
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: