Provider Demographics
NPI:1295949444
Name:RODERICK K SHAW III DMD PA
Entity type:Organization
Organization Name:RODERICK K SHAW III DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DM
Authorized Official - Phone:850-973-6427
Mailing Address - Street 1:255 NE DUVAL AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340
Mailing Address - Country:US
Mailing Address - Phone:850-973-6427
Mailing Address - Fax:850-973-9646
Practice Address - Street 1:255 NE DUVAL AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340
Practice Address - Country:US
Practice Address - Phone:850-973-6427
Practice Address - Fax:850-973-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10977122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty