Provider Demographics
NPI:1326215005
Name:SDSDDS, LLC
Entity Type:Organization
Organization Name:SDSDDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHUFFLEBARGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-369-3069
Mailing Address - Street 1:1850 GRAND PORTAGE TRL
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-9593
Mailing Address - Country:US
Mailing Address - Phone:937-369-3069
Mailing Address - Fax:937-431-1268
Practice Address - Street 1:1850 GRAND PORTAGE TRL
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-9593
Practice Address - Country:US
Practice Address - Phone:937-369-3069
Practice Address - Fax:937-431-1268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30021080122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty