Provider Demographics
NPI:1174751036
Name:ALEX, SHAUN (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:
Last Name:ALEX
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S ELMWOOD AVE
Mailing Address - Street 2:3
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4015
Mailing Address - Country:US
Mailing Address - Phone:202-321-8810
Mailing Address - Fax:
Practice Address - Street 1:3020 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1312
Practice Address - Country:US
Practice Address - Phone:773-463-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0280301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice