Provider Demographics
NPI:1801324298
Name:CUSTER, SHAWN MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:MICHAEL
Last Name:CUSTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 W 16TH ST STE 8E
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6862
Mailing Address - Country:US
Mailing Address - Phone:970-352-5448
Mailing Address - Fax:
Practice Address - Street 1:3400 W 16TH ST STE 8E
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6862
Practice Address - Country:US
Practice Address - Phone:970-352-5448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002033941223G0001X
NE73631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice