Provider Demographics
NPI:1093854168
Name:SHIVASHANKAR, NANJAPPA (DDS)
Entity Type:Individual
Prefix:DR
First Name:NANJAPPA
Middle Name:
Last Name:SHIVASHANKAR
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 1:12421 SAN JOSE BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8663
Mailing Address - Country:US
Mailing Address - Phone:904-268-7552
Mailing Address - Fax:904-268-9792
Practice Address - Street 1:12421 SAN JOSE BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8663
Practice Address - Country:US
Practice Address - Phone:904-268-7552
Practice Address - Fax:904-268-9792
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL93171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice