Healthcare Provider Details

I. General information

NPI: 1578497426
Provider Name (Legal Business Name): SHAW PARK DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 S MERAMEC AVE STE 311
SAINT LOUIS MO
63105-3511
US

IV. Provider business mailing address

501 EISENHOWER BLVD
TROY IL
62294-3341
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-2420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIPALI THAKKER
Title or Position: MANAGING MEMBER
Credential:
Phone: 618-558-2510