Provider Demographics
NPI:1629100227
Name:WILLETTE SHAEFFER DMD PA
Entity Type:Organization
Organization Name:WILLETTE SHAEFFER DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAEFFER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-642-1139
Mailing Address - Street 1:2711-2 SAINT JOHNS BLUFF RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-3703
Mailing Address - Country:US
Mailing Address - Phone:904-642-1139
Mailing Address - Fax:904-642-7858
Practice Address - Street 1:2711-2 SAINT JOHNS BLUFF RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-3703
Practice Address - Country:US
Practice Address - Phone:904-642-1139
Practice Address - Fax:904-642-7858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty