MEDICARE: LORI SHATTUCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12010537A	IN

General Provider Information

NPI Number	:	1164696357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI SHATTUCK

Provider Business Mailing Address
First Line	:	9310 N MERIDIAN ST STE 200
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-0001
Country	:	US
Telephone Number	:	317-846-6125
Fax Number	:

Provider Business Practice Location Address
First Line	:	9310 N MERIDIAN ST STE 200
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-0001
Country	:	US
Telephone Number	:	317-846-6125
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2008
Last Update Date	:	04/17/2008

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Directions to “ LORI SHATTUCK ” Practice Location

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