Provider Demographics
NPI:1164492104
Name:ROUNDY, SHAD DEMAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHAD
Middle Name:DEMAR
Last Name:ROUNDY
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 1:1601 MEDICAL ARTS BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3460
Mailing Address - Country:US
Mailing Address - Phone:765-298-4400
Mailing Address - Fax:765-298-4940
Practice Address - Street 1:1601 MEDICAL ARTS BLVD STE 301
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3460
Practice Address - Country:US
Practice Address - Phone:765-298-4400
Practice Address - Fax:765-298-4940
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1731223S0112X
IN12012276A1223S0112X
IN12012276B1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0083Medicaid
FR5170701OtherFEDERAL DEA ANDERSON, IN
BR9479444OtherFEDERAL DEA
AKDD0083Medicaid