Provider Demographics
NPI:1144605403
Name:MACKERT, SHAD B (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAD
Middle Name:B
Last Name:MACKERT
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 1:12459 S 300 E STE 202
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-1899
Mailing Address - Country:US
Mailing Address - Phone:854-301-2003
Mailing Address - Fax:
Practice Address - Street 1:12459 S 300 E STE 202
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-1899
Practice Address - Country:US
Practice Address - Phone:385-430-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10220776-89031223P0700X
MI29010214791223P0700X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice