Provider Demographics
NPI:1225200173
Name:SHAWN T ENGEBRETSEN DMD P A
Entity Type:Organization
Organization Name:SHAWN T ENGEBRETSEN DMD P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ENGEBRETSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:772-223-0600
Mailing Address - Street 1:1825 NW BRIGHT RIVER PT
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-9407
Mailing Address - Country:US
Mailing Address - Phone:772-692-1194
Mailing Address - Fax:
Practice Address - Street 1:841 E OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2427
Practice Address - Country:US
Practice Address - Phone:772-223-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00094271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAN643Medicare PIN
FLT85393Medicare UPIN