Provider Demographics
NPI:1508873894
Name:SHAW, CHAD J (DDS)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:J
Last Name:SHAW
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 1:1409 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1119
Mailing Address - Country:US
Mailing Address - Phone:574-936-8787
Mailing Address - Fax:
Practice Address - Street 1:1409 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1119
Practice Address - Country:US
Practice Address - Phone:574-936-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010465A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice