Provider Demographics
NPI:1740960830
Name:SHAKER, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SHAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 SHADOW PATH DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-5510
Mailing Address - Country:US
Mailing Address - Phone:386-334-2850
Mailing Address - Fax:
Practice Address - Street 1:1603 S HIAWASSEE RD STE 135
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6439
Practice Address - Country:US
Practice Address - Phone:407-293-8324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist