Provider Demographics
NPI:1326578865
Name:PERSON, SHADAE (DDS)
Entity Type:Individual
Prefix:
First Name:SHADAE
Middle Name:
Last Name:PERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SHADAE
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18070 S TAMIAMI TRL STE 14
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4602
Mailing Address - Country:US
Mailing Address - Phone:239-288-7275
Mailing Address - Fax:
Practice Address - Street 1:18070 S TAMIAMI TRL STE 14
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4602
Practice Address - Country:US
Practice Address - Phone:239-288-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014156861223G0001X, 122300000X
FLDN24803122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice