Provider Demographics
NPI:1710006218
Name:SHAW, RANDOLPH S (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:S
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 1:1080 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2223
Mailing Address - Country:US
Mailing Address - Phone:937-836-7592
Mailing Address - Fax:937-836-6269
Practice Address - Street 1:1080 UNION BLVD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2223
Practice Address - Country:US
Practice Address - Phone:937-836-7592
Practice Address - Fax:937-836-6269
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH178791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice