Healthcare Provider Details

I. General information

NPI: 1700515632
Provider Name (Legal Business Name): SHADOE STEWART DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1591 YANCEYVILLE ST STE 300B
GREENSBORO NC
27405-6944
US

IV. Provider business mailing address

1591 YANCEYVILLE ST STE 300B
GREENSBORO NC
27405-6944
US

V. Phone/Fax

Practice location:
  • Phone: 336-274-1950
  • Fax: 336-274-1951
Mailing address:
  • Phone: 336-274-1950
  • Fax: 336-274-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12739
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12739
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: