Provider Demographics
NPI:1508877515
Name:SHAW, JERRY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
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 1:1761 N 2000 W
Mailing Address - Street 2:
Mailing Address - City:FARR WEST
Mailing Address - State:UT
Mailing Address - Zip Code:84404
Mailing Address - Country:US
Mailing Address - Phone:801-731-4850
Mailing Address - Fax:801-731-4852
Practice Address - Street 1:1761 N 2000 W
Practice Address - Street 2:
Practice Address - City:FARR WEST
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-731-4850
Practice Address - Fax:801-731-4852
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT132357122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics