Provider Demographics
NPI:1669746418
Name:SHAH, BIRAJ M (DDS, MD)
Entity type:Individual
Prefix:
First Name:BIRAJ
Middle Name:M
Last Name:SHAH
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 W POLK ST STE 612
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:312-864-3202
Mailing Address - Fax:
Practice Address - Street 1:1900 W POLK ST STE 612
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-864-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-25
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0317241223S0112X
IL036-147405204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery