Provider Demographics
NPI:1326372574
Name:SHAHAN, DALE DAWSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:DAWSON
Last Name:SHAHAN
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 1:636 HAMPSHIRE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3054
Mailing Address - Country:US
Mailing Address - Phone:217-228-0101
Mailing Address - Fax:217-222-7011
Practice Address - Street 1:636 HAMPSHIRE ST STE 102
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3054
Practice Address - Country:US
Practice Address - Phone:217-228-0101
Practice Address - Fax:217-222-7011
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0130671223G0001X
IL021.0007291223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice