Provider Demographics
NPI:1538905120
Name:DEY, SHWETA
Entity type:Individual
Prefix:
First Name:SHWETA
Middle Name:
Last Name:DEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 RUDDER LN APT 112
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8780
Mailing Address - Country:US
Mailing Address - Phone:323-961-2735
Mailing Address - Fax:
Practice Address - Street 1:1401 N VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2296
Practice Address - Country:US
Practice Address - Phone:309-319-9577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.035444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist