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General NPI Number Information
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NPI Number | 1073997722
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Entity Type | Organization
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Legal Business Name | WEST LOOP FAMILY DENTAL LLC
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Dates
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Enumeration Date | 07/13/2015
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Last Update Date | 10/19/2015
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Provider Practice Location Address
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Address Line | 1202 W MADISON ST
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City | CHICAGO
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State | IL
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Zip | 60607-1908
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Country | US
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Telephone | 312-724-7161
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Fax |
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Provider Business Mailing Address
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Address Line | 1202 W MADISON ST
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City | CHICAGO
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State | IL
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Zip | 60607-1908
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Country | US
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Telephone | 312-724-7161
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. ANKITA SHAH
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Credential | DMD
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Telephone | 818-324-3315
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019027537
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License Number State | IL
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