MEDICARE: DR. SHAWN GHODS DMD

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	25701	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174100903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAWN GHODS DMD

Provider Business Mailing Address
First Line	:	5311 NW TORINO LAKES CIR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-3239
Country	:	US
Telephone Number	:	571-442-4884
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 SW ST LUCIE W BLVD
Second Line	:	SUITE #206
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986
Country	:	US
Telephone Number	:	772-807-1451
Fax Number	:

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

Provider Enumeration Date	:	03/26/2021
Last Update Date	:	03/26/2021

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