Healthcare Provider Details

I. General information

NPI: 1528065992
Provider Name (Legal Business Name): DAVID SHAFER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

263 FARMINGTON AVE PROVIDER ENROLLMENT
FARMINGTON CT
06030-2212
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-3300
  • Fax: 860-679-1099
Mailing address:
  • Phone: 860-679-7503
  • Fax: 860-679-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number007624
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number007624
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: