Healthcare Provider Details

I. General information

NPI: 1356898050
Provider Name (Legal Business Name): SOUTH SHORE SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9270 WICKER AVE SUITE E AND F
SAINT JOHN IN
46373-8508
US

IV. Provider business mailing address

9270 WICKER AVE SUITE E AND F
SAINT JOHN IN
46373-8508
US

V. Phone/Fax

Practice location:
  • Phone: 219-627-3133
  • Fax:
Mailing address:
  • Phone: 219-627-3133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011455A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12011456A
License Number StateIN

VIII. Authorized Official

Name: DR. ROGER K SHIEH
Title or Position: OWNER
Credential: DDS
Phone: 219-716-1259