Provider Demographics
NPI:1174142525
Name:SHACHAT, MATTHEW (DMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SHACHAT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W VAN BUREN ST # F6
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3909
Mailing Address - Country:US
Mailing Address - Phone:312-441-0096
Mailing Address - Fax:773-943-7344
Practice Address - Street 1:212 W VAN BUREN ST # F6
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-3909
Practice Address - Country:US
Practice Address - Phone:312-441-0096
Practice Address - Fax:773-943-7344
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.032689122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program