Provider Demographics
NPI:1205111432
Name:JERRY L. SHAW, D.D.S.
Entity type:Organization
Organization Name:JERRY L. SHAW, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-731-4850
Mailing Address - Street 1:1761 N. 2000 W.
Mailing Address - Street 2:
Mailing Address - City:FARR WEST
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9541
Mailing Address - Country:US
Mailing Address - Phone:801-731-4850
Mailing Address - Fax:801-731-4852
Practice Address - Street 1:1761 N. 2000 W.
Practice Address - Street 2:
Practice Address - City:FARR WEST
Practice Address - State:UT
Practice Address - Zip Code:84404-9541
Practice Address - Country:US
Practice Address - Phone:801-731-4850
Practice Address - Fax:801-731-4852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1323571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529447754018Medicaid