Healthcare Provider Details

I. General information

NPI: 1215932504
Provider Name (Legal Business Name): STEPHEN MARK SHALL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5690 MONROE ST
SYLVANIA OH
43560-2736
US

IV. Provider business mailing address

5690 MONROE ST STE A
SYLVANIA OH
43560-2736
US

V. Phone/Fax

Practice location:
  • Phone: 419-479-3939
  • Fax: 419-479-3933
Mailing address:
  • Phone: 419-479-3939
  • Fax: 419-479-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number16634
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number30.016634
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: