Provider Demographics
NPI:1982711818
Name:JONATHAN R SHAW DDS PS
Entity Type:Organization
Organization Name:JONATHAN R SHAW DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORP
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-684-6138
Mailing Address - Street 1:214 WEST BIRCH
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114
Mailing Address - Country:US
Mailing Address - Phone:509-684-6138
Mailing Address - Fax:509-684-0884
Practice Address - Street 1:214 WEST BIRCH
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114
Practice Address - Country:US
Practice Address - Phone:509-684-6138
Practice Address - Fax:509-684-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4798122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5503107Medicaid
WA784537OtherUNITED CONCORDIA INS