Provider Demographics
NPI:1790966141
Name:SHAW, JUDITH VICTORIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:VICTORIA
Last Name:SHAW
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 1:663 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-4404
Mailing Address - Country:US
Mailing Address - Phone:650-952-9541
Mailing Address - Fax:650-952-9623
Practice Address - Street 1:663 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-4404
Practice Address - Country:US
Practice Address - Phone:650-952-9541
Practice Address - Fax:650-952-9623
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36621122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist