Healthcare Provider Details

I. General information

NPI: 1760498117
Provider Name (Legal Business Name): MICHAEL HALL SHAHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 DUDLEY AVE STE 2
PARKERSBURG WV
26101-3476
US

IV. Provider business mailing address

2000 DUDLEY AVE STE 2
PARKERSBURG WV
26101-3476
US

V. Phone/Fax

Practice location:
  • Phone: 304-422-8400
  • Fax:
Mailing address:
  • Phone: 304-422-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2334
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: