MEDICARE: DR. BRINDA R 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	122300000X	Dentist	1002148	WI

General Provider Information

NPI Number	:	1477115541
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRINDA R SHAH DDS

Provider Business Mailing Address
First Line	:	9007 HARMS RD
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-2518
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9007 HARMS RD
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-2518
Country	:	US
Telephone Number	:	312-437-3194
Fax Number	:

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

Provider Enumeration Date	:	06/28/2019
Last Update Date	:	07/06/2019

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