Healthcare Provider Details

I. General information

NPI: 1801176136
Provider Name (Legal Business Name): SHAWN C COUNTRYMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 7095, BOX 185 BLDG. 865
APO AE
09824
US

IV. Provider business mailing address

UNIT 7095, BOX 185 BLDG. 865
APO AE
09824
US

V. Phone/Fax

Practice location:
  • Phone: 314-676-3380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberN-9870
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number00205167
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number30418
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberN-9870
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: