Provider Demographics
NPI:1013016823
Name:SHUPE, JAMES A JR (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:SHUPE
Suffix:JR
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 1:3030 LAKE AVE
Mailing Address - Street 2:SUITE 15
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5428
Mailing Address - Country:US
Mailing Address - Phone:260-422-8419
Mailing Address - Fax:260-422-3591
Practice Address - Street 1:3030 LAKE AVE
Practice Address - Street 2:SUITE 15
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5428
Practice Address - Country:US
Practice Address - Phone:260-422-8419
Practice Address - Fax:260-422-3591
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008822A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry