Provider Demographics
NPI:1518369933
Name:SHAO, CHONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHONG
Middle Name:
Last Name:SHAO
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 1:900 E 3RD ST STE A
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-2066
Mailing Address - Country:US
Mailing Address - Phone:319-462-2313
Mailing Address - Fax:
Practice Address - Street 1:900 E 3RD ST STE A
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205
Practice Address - Country:US
Practice Address - Phone:319-462-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA9511122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist