Healthcare Provider Details

I. General information

NPI: 1992724074
Provider Name (Legal Business Name): EDWARD V. SHAGAM, .D.D.S., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 GARDEN ST # 11
MOUNT HOLLY NJ
08060-1839
US

IV. Provider business mailing address

9 GARDEN ST # 11
MOUNT HOLLY NJ
08060-1839
US

V. Phone/Fax

Practice location:
  • Phone: 609-267-2266
  • Fax: 856-983-1334
Mailing address:
  • Phone: 609-267-2266
  • Fax: 856-983-1334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS 11833
License Number StateNJ

VIII. Authorized Official

Name: DR. EDWARD V SHAGAM
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 609-267-2266