Healthcare Provider Details

I. General information

NPI: 1417236613
Provider Name (Legal Business Name): KENNETH DEMETRIC SHUMATE D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 CRAIN HWY SUITE 202
WALDORF MD
20601-2801
US

IV. Provider business mailing address

3010 CRAIN HWY SUITE 202
WALDORF MD
20601-2801
US

V. Phone/Fax

Practice location:
  • Phone: 240-518-8928
  • Fax: 240-518-8931
Mailing address:
  • Phone: 240-518-8928
  • Fax: 240-518-8931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14944
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401413457
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: