Healthcare Provider Details

I. General information

NPI: 1497020275
Provider Name (Legal Business Name): JASON SHOE DMD MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 WILSON AVE SUITE E
HANOVER PA
17331-1469
US

IV. Provider business mailing address

141 WILSON AVE SUITE E
HANOVER PA
17331-1469
US

V. Phone/Fax

Practice location:
  • Phone: 717-634-2461
  • Fax:
Mailing address:
  • Phone: 717-634-2461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS037178
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14277
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: