Provider Demographics
NPI:1467570606
Name:SHULTS, LAWRENCE (DDS MSD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:SHULTS
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3549 E BROWN RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5508
Mailing Address - Country:US
Mailing Address - Phone:480-634-5686
Mailing Address - Fax:888-620-3210
Practice Address - Street 1:3549 E BROWN RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5508
Practice Address - Country:US
Practice Address - Phone:480-634-5686
Practice Address - Fax:888-620-3210
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD69531223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ117337Medicaid