Healthcare Provider Details

I. General information

NPI: 1104639970
Provider Name (Legal Business Name): EMANUEL SHADDAIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 MILITARY TRL
JUPITER FL
33458-7879
US

IV. Provider business mailing address

3955 DESIGN CENTER DR APT 454
PALM BEACH GARDENS FL
33410-4366
US

V. Phone/Fax

Practice location:
  • Phone: 561-786-8413
  • Fax:
Mailing address:
  • Phone: 516-974-3297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN31378
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: