MEDICARE: SOUTH SHORE SMILES LLC

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	1223P0221X	Pediatric Dentistry	12011456A	IN
2	1223G0001X	General Practice Dentistry	12011455A	IN

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356898050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SHORE SMILES LLC

Provider Business Mailing Address
First Line	:	9270 WICKER AVE
Second Line	:	SUITE E AND F
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8508
Country	:	US
Telephone Number	:	219-627-3133
Fax Number	:

Provider Business Practice Location Address
First Line	:	9270 WICKER AVE
Second Line	:	SUITE E AND F
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8508
Country	:	US
Telephone Number	:	219-627-3133
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROGER K SHIEH
Credential	:	DDS
Telephone Number	:	219-716-1259

Provider Enumeration Date	:	09/09/2016
Last Update Date	:	09/09/2016

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Directions to “SOUTH SHORE SMILES LLC ” Practice Location

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