Healthcare Provider Details

I. General information

NPI: 1457930836
Provider Name (Legal Business Name): MAXIMILIAN JAMES SHUMAKE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10615 N HAYDEN RD STE C-104
SCOTTSDALE AZ
85260-5734
US

IV. Provider business mailing address

7950 E STARLIGHT WAY UNIT 246
SCOTTSDALE AZ
85250-6142
US

V. Phone/Fax

Practice location:
  • Phone: 480-905-7171
  • Fax:
Mailing address:
  • Phone: 239-777-6788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011530
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: