Provider Demographics
NPI:1568992022
Name:SHAKAMAK FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:SHAKAMAK FAMILY DENTISTRY, LLC
Other - Org Name:SHAKAMAK FAMILY DENTISTRY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:KELLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-665-2275
Mailing Address - Street 1:190 C ST NW
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-1328
Mailing Address - Country:US
Mailing Address - Phone:812-847-8646
Mailing Address - Fax:812-847-8761
Practice Address - Street 1:206 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:JASONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47438-1520
Practice Address - Country:US
Practice Address - Phone:812-665-2275
Practice Address - Fax:812-665-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012106A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201234800AMedicaid