MEDICARE: ANKUR V SHAH DMD PC

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	1223G0001X	General Practice Dentistry	019027891	IL

General Provider Information

NPI Number	:	1821317421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANKUR V SHAH DMD PC

Provider Business Mailing Address
First Line	:	600 N MCCLURG CT
Second Line	:	#2507A
City	:	CHICAGO
State	:	IL
Zip	:	60611-3044
Country	:	US
Telephone Number	:	847-800-3604
Fax Number	:

Provider Business Practice Location Address
First Line	:	5050 S KEDZIE AVE
Second Line	:	UNIT A
City	:	CHICAGO
State	:	IL
Zip	:	60632-3009
Country	:	US
Telephone Number	:	773-778-2200
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. ANKUR VINOD SHAH
Credential	:	DMD
Telephone Number	:	847-800-3604

Provider Enumeration Date	:	05/20/2010
Last Update Date	:	05/20/2010

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