Provider Demographics
NPI:1790990299
Name:DOUGLAS, SHAWN JAMES (DDS, MHA)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:JAMES
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DDS, MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 WELLNESS LN BLDG 3
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-5359
Mailing Address - Country:US
Mailing Address - Phone:727-372-3200
Mailing Address - Fax:
Practice Address - Street 1:1821 WELLNESS LN BLDG 3
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-5359
Practice Address - Country:US
Practice Address - Phone:727-372-3200
Practice Address - Fax:727-372-0505
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FLDN 174191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies