Provider Demographics
NPI:1790804367
Name:SHABO, MALCOLM DREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:DREW
Last Name:SHABO
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 1:8307 WATERSBEND LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-8705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5958 SNOW HILL RD
Practice Address - Street 2:STE 144 PMB 204
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-7833
Practice Address - Country:US
Practice Address - Phone:423-894-4084
Practice Address - Fax:423-894-4086
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN76311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice