Healthcare Provider Details

I. General information

NPI: 1073676953
Provider Name (Legal Business Name): JOHN R. SHAW DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 S MAIN ST
CENTRAL SQUARE NY
13036-3500
US

IV. Provider business mailing address

36 ALDEN AVE
AUBURN NY
13021-4322
US

V. Phone/Fax

Practice location:
  • Phone: 315-676-3001
  • Fax: 315-676-3785
Mailing address:
  • Phone: 315-252-8996
  • Fax: 315-252-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number035014
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: