Provider Demographics
NPI:1417236613
Name:SHUMATE, KENNETH DEMETRIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DEMETRIC
Last Name:SHUMATE
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 1:3010 CRAIN HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-2801
Mailing Address - Country:US
Mailing Address - Phone:240-518-8928
Mailing Address - Fax:240-518-8931
Practice Address - Street 1:3010 CRAIN HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2801
Practice Address - Country:US
Practice Address - Phone:240-518-8928
Practice Address - Fax:240-518-8931
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD149441223G0001X
VA04014134571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD067013800Medicaid