Provider Demographics
NPI:1215026612
Name:SHAW, GARY GRAHAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:GRAHAM
Last Name:SHAW
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:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337-0145
Mailing Address - Country:US
Mailing Address - Phone:435-257-3000
Mailing Address - Fax:435-257-7429
Practice Address - Street 1:435 W 600 N
Practice Address - Street 2:
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337-2411
Practice Address - Country:US
Practice Address - Phone:435-257-3000
Practice Address - Fax:435-257-7429
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9836033599231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice