Provider Demographics
NPI:1194852806
Name:SHOHA, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:SHOHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23400 MICHIGAN AVE
Mailing Address - Street 2:STE 112
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1924
Mailing Address - Country:US
Mailing Address - Phone:313-565-9118
Mailing Address - Fax:
Practice Address - Street 1:23400 MICHIGAN AVE
Practice Address - Street 2:STE 112
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1924
Practice Address - Country:US
Practice Address - Phone:313-565-9118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI95631223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU23536Medicare UPIN