Healthcare Provider Details

I. General information

NPI: 1689987844
Provider Name (Legal Business Name): PAUL RICHARD SHAMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9674 SOUTH RUN OAKS DR.
FAIRFAX STATION VA
22039-2629
US

IV. Provider business mailing address

9674 SOUTH RUN OAKS DR.
FAIRFAX STATION VA
22039-2629
US

V. Phone/Fax

Practice location:
  • Phone: 703-643-3041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN12279
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6663
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: