Provider Demographics
NPI:1912000977
Name:JACK C SHADER DDS PC
Entity Type:Organization
Organization Name:JACK C SHADER DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHADER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-625-9444
Mailing Address - Street 1:6300 SASHABAW RD
Mailing Address - Street 2:STE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48436
Mailing Address - Country:US
Mailing Address - Phone:248-625-9444
Mailing Address - Fax:248-625-4813
Practice Address - Street 1:6300 SASHABAW RD
Practice Address - Street 2:STE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48436
Practice Address - Country:US
Practice Address - Phone:248-625-9444
Practice Address - Fax:248-625-4813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI111261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty