Provider Demographics
NPI:1275272213
Name:SHAW, WESLEY MITCHELL (DMD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:MITCHELL
Last Name:SHAW
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 1:1624 TATE BLVD SE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-4244
Mailing Address - Country:US
Mailing Address - Phone:828-267-6800
Mailing Address - Fax:
Practice Address - Street 1:1624 TATE BLVD SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4244
Practice Address - Country:US
Practice Address - Phone:828-267-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-28
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist