Healthcare Provider Details

I. General information

NPI: 1073716338
Provider Name (Legal Business Name): FREDRICK SHAW DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W 38TH ST STE. 34
AUSTIN TX
78731-6321
US

IV. Provider business mailing address

1500 W 38TH ST STE. 34
AUSTIN TX
78731-6321
US

V. Phone/Fax

Practice location:
  • Phone: 512-451-7491
  • Fax: 512-451-5388
Mailing address:
  • Phone: 512-451-7491
  • Fax: 512-451-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number17867
License Number StateTX

VIII. Authorized Official

Name: MR. ADRIAN F RAMOS
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 512-451-7491