Healthcare Provider Details

I. General information

NPI: 1396789350
Provider Name (Legal Business Name): DR. SHAWN TORLIEF ENGEBRETSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 E OCEAN BLVD
STUART FL
34994-2427
US

IV. Provider business mailing address

1825 NW BRIGHT RIVER PT
STUART FL
34994-9407
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-0600
  • Fax: 772-223-0617
Mailing address:
  • Phone: 772-223-0600
  • Fax: 772-223-0617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN0009427
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: