Provider Demographics
NPI:1457697542
Name:SHAWN WIDICK, D.D.S. INC.
Entity Type:Organization
Organization Name:SHAWN WIDICK, D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-433-6907
Mailing Address - Street 1:704 HEALDSBURG AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-3651
Mailing Address - Country:US
Mailing Address - Phone:707-433-6907
Mailing Address - Fax:707-433-1302
Practice Address - Street 1:704 HEALDSBURG AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3651
Practice Address - Country:US
Practice Address - Phone:707-433-6907
Practice Address - Fax:707-433-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty