Provider Demographics
NPI:1700092418
Name:SHOOTES, LAVENDRA V (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAVENDRA
Middle Name:V
Last Name:SHOOTES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 DAWSON RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-1690
Mailing Address - Country:US
Mailing Address - Phone:229-888-2488
Mailing Address - Fax:229-888-2440
Practice Address - Street 1:2722 DAWSON RD
Practice Address - Street 2:SUITE 12
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-1690
Practice Address - Country:US
Practice Address - Phone:229-888-2488
Practice Address - Fax:229-888-2440
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0125131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000959329BMedicaid