Provider Demographics
NPI:1689723199
Name:SHUPING, GEORGE BRYAN
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:BRYAN
Last Name:SHUPING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HARBOR SHORE CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8911
Mailing Address - Country:US
Mailing Address - Phone:704-663-1138
Mailing Address - Fax:
Practice Address - Street 1:438 WILLIAMSON RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9185
Practice Address - Country:US
Practice Address - Phone:704-664-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC65091223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990128Medicaid
NC902F1OtherBCBS PROVIDER #
NC6509OtherLICENSE #