Provider Demographics
NPI:1619199734
Name:SHAW, BRUCE MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MICHAEL
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 1:1111 LINCOLN RD.
Mailing Address - Street 2:SUITE 740
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139
Mailing Address - Country:US
Mailing Address - Phone:305-532-5044
Mailing Address - Fax:
Practice Address - Street 1:1111 LINCOLN RD.
Practice Address - Street 2:SUITE 740
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139
Practice Address - Country:US
Practice Address - Phone:305-532-5044
Practice Address - Fax:305-531-1011
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN74191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice