Provider Demographics
NPI:1467535203
Name:SHADER, JACK CARL (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:CARL
Last Name:SHADER
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 1:6300 SASHABAW RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-625-9444
Mailing Address - Fax:248-625-4813
Practice Address - Street 1:6300 SASHABAW RD
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2269
Practice Address - Country:US
Practice Address - Phone:248-625-9444
Practice Address - Fax:248-625-4813
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010111261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice