MEDICARE: REENA P SHAH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	019025181	IL

General Provider Information

NPI Number	:	1053490383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REENA P SHAH DDS

Provider Business Mailing Address
First Line	:	2300 N CHILDRENS PLZ
Second Line	:	#64
City	:	CHICAGO
State	:	IL
Zip	:	60614-3363
Country	:	US
Telephone Number	:	312-573-4515
Fax Number	:	312-573-8405

Provider Business Practice Location Address
First Line	:	467 W DEMING PL
Second Line	:	SUITE 900
City	:	CHICAGO
State	:	IL
Zip	:	60614-1881
Country	:	US
Telephone Number	:	773-327-2950
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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