Provider Demographics
NPI:1396789350
Name:ENGEBRETSEN, SHAWN TORLIEF
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:TORLIEF
Last Name:ENGEBRETSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 NW BRIGHT RIVER PT
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-9407
Mailing Address - Country:US
Mailing Address - Phone:772-223-0600
Mailing Address - Fax:772-223-0617
Practice Address - Street 1:841 E OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2427
Practice Address - Country:US
Practice Address - Phone:772-223-0600
Practice Address - Fax:772-223-0617
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00094271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072275800Medicaid
FLT85393Medicare UPIN
FL67640XMedicare PIN