Provider Demographics
NPI:1356358030
Name:SHAWD, NICHOLAS JON (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JON
Last Name:SHAWD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 E KEVIN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-2070
Mailing Address - Country:US
Mailing Address - Phone:605-498-5907
Mailing Address - Fax:605-498-9147
Practice Address - Street 1:725 E KEVIN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:TEA
Practice Address - State:SD
Practice Address - Zip Code:57064-2070
Practice Address - Country:US
Practice Address - Phone:605-498-5907
Practice Address - Fax:605-498-9147
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD M9931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice