Provider Demographics
NPI:1710166848
Name:SHABANA, MAIE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAIE
Middle Name:M
Last Name:SHABANA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 WEST 8TH STREET
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:719-583-1801
Practice Address - Street 1:3506 VILLAGE CT
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-1428
Practice Address - Country:US
Practice Address - Phone:219-985-3133
Practice Address - Fax:219-985-3139
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010197211223D0001X
IN12011765A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health