Provider Demographics
NPI:1366505265
Name:SHAW, E CARL (DMD)
Entity Type:Individual
Prefix:MR
First Name:E
Middle Name:CARL
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 1:1267 RUSSELL PKWY
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5582
Mailing Address - Country:US
Mailing Address - Phone:478-923-0253
Mailing Address - Fax:478-923-6906
Practice Address - Street 1:1267 RUSSELL PKWY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5582
Practice Address - Country:US
Practice Address - Phone:478-923-0253
Practice Address - Fax:478-923-6906
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0085431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00311341AMedicaid