Provider Demographics
NPI:1659544534
Name:SHUE, MARK TIMOTHY (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TIMOTHY
Last Name:SHUE
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 1:1240 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-4463
Mailing Address - Country:US
Mailing Address - Phone:937-324-5678
Mailing Address - Fax:937-324-0198
Practice Address - Street 1:1240 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-4463
Practice Address - Country:US
Practice Address - Phone:937-324-5678
Practice Address - Fax:937-324-0198
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15953122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist