Provider Demographics
NPI:1447626700
Name:SHAH, NIKETA (DMD)
Entity type:Individual
Prefix:
First Name:NIKETA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:NIKETA
Other - Middle Name:V
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1745 N CLYBOURN AVE
Mailing Address - Street 2:APT 2S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8991
Mailing Address - Country:US
Mailing Address - Phone:630-344-3551
Mailing Address - Fax:
Practice Address - Street 1:106 W BARTLETT AVE
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-7880
Practice Address - Country:US
Practice Address - Phone:630-830-4930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030445122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist