Provider Demographics
NPI:1023506433
Name:SHAWN M CUSTER DENTAL PLLC
Entity type:Organization
Organization Name:SHAWN M CUSTER DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-669-4971
Mailing Address - Street 1:3400 W 16TH ST STE 8E
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6862
Mailing Address - Country:US
Mailing Address - Phone:970-352-5448
Mailing Address - Fax:
Practice Address - Street 1:3400 W 16TH ST STE 8E
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6862
Practice Address - Country:US
Practice Address - Phone:970-352-5448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00203394261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental