Provider Demographics
NPI:1023170404
Name:SHROFF, TINA A (DDS)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:A
Last Name:SHROFF
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 E SIBLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2836
Mailing Address - Country:US
Mailing Address - Phone:708-849-9520
Mailing Address - Fax:908-849-9584
Practice Address - Street 1:1021 E SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2836
Practice Address - Country:US
Practice Address - Phone:708-849-9520
Practice Address - Fax:908-849-9584
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024341122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004721Medicaid