Provider Demographics
NPI:1831363027
Name:SHAMROCK DENTAL GROUP, LLC
Entity type:Organization
Organization Name:SHAMROCK DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HABERKORN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS , MBA
Authorized Official - Phone:573-334-6009
Mailing Address - Street 1:2502 WILLIAM ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5763
Mailing Address - Country:US
Mailing Address - Phone:573-334-6009
Mailing Address - Fax:573-334-7675
Practice Address - Street 1:2502 WILLIAM ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5763
Practice Address - Country:US
Practice Address - Phone:573-334-6009
Practice Address - Fax:573-334-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020317561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005255/106930Medicaid