Provider Demographics
NPI:1073676953
Name:SHAW, JOHN R (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SHAW
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 1:36 ALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4322
Mailing Address - Country:US
Mailing Address - Phone:315-252-8996
Mailing Address - Fax:315-252-8996
Practice Address - Street 1:537 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-3500
Practice Address - Country:US
Practice Address - Phone:315-676-3001
Practice Address - Fax:315-676-3785
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0350141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics