Provider Demographics
NPI:1780255943
Name:SHUTTLEWORTH, SAMANTHA (DDS)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SHUTTLEWORTH
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 1:5116 RALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1348
Mailing Address - Country:US
Mailing Address - Phone:610-283-9612
Mailing Address - Fax:
Practice Address - Street 1:2620 E 62ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2934
Practice Address - Country:US
Practice Address - Phone:317-251-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013672A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist