MEDICARE: WASHINGTON DENTAL STUDIO

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

General Provider Information

NPI Number	:	1720664436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON DENTAL STUDIO

Provider Business Mailing Address
First Line	:	10735 CLOCKTOWER DR
Second Line	:	UNIT 303
City	:	COUNTRYSIDE
State	:	IL
Zip	:	60525
Country	:	US
Telephone Number	:	832-766-0144
Fax Number	:

Provider Business Practice Location Address
First Line	:	1003 S WASHINGTON ST STE 225
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-7444
Country	:	US
Telephone Number	:	832-766-0144
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROHAN VIKRAM SHAH
Credential	:	DDS
Telephone Number	:	832-766-0144

Provider Enumeration Date	:	03/23/2021
Last Update Date	:	03/23/2021

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Directions to “WASHINGTON DENTAL STUDIO ” Practice Location

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