Provider Demographics
NPI:1891942165
Name:SHAW, RANDALL LOREN (DDS,MS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:LOREN
Last Name:SHAW
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2139
Mailing Address - Country:US
Mailing Address - Phone:248-931-1151
Mailing Address - Fax:248-594-2221
Practice Address - Street 1:18860 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2666
Practice Address - Country:US
Practice Address - Phone:248-565-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI138191223X0400X
MI29010.0138191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty