Healthcare Provider Details

I. General information

NPI: 1437152956
Provider Name (Legal Business Name): JOHN C SHAFER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 PACIFIC COAST HWY STE C
HERMOSA BEACH CA
90254-3951
US

IV. Provider business mailing address

1100 PACIFIC COAST HWY STE C
HERMOSA BEACH CA
90254-3951
US

V. Phone/Fax

Practice location:
  • Phone: 310-374-9608
  • Fax: 310-374-5824
Mailing address:
  • Phone: 310-374-9608
  • Fax: 310-374-5824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL27369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: