=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932384211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERWYN OAK PARK FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2008
-----------------------------------------------------
Last Update Date | 01/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3240 OAK PARK AVE
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-5470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-788-6768
-----------------------------------------------------
Fax | 708-788-3666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3240 OAK PARK AVE
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-5470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-788-6768
-----------------------------------------------------
Fax | 708-788-3666
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PAYAL SHAH
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 708-788-6768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------