Provider Demographics
NPI:1871025429
Name:SHAMMAA ORTHODONTICS
Entity Type:Organization
Organization Name:SHAMMAA ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMMAA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:304-925-4258
Mailing Address - Street 1:417 GRAND PARK DR STE 107
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4063
Mailing Address - Country:US
Mailing Address - Phone:304-720-7771
Mailing Address - Fax:304-925-4259
Practice Address - Street 1:417 GRAND PARK DR STE 107
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26105-4063
Practice Address - Country:US
Practice Address - Phone:304-720-7771
Practice Address - Fax:304-925-4259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV31921223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0077946000Medicaid