=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164492104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAD DEMAR ROUNDY DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 MEDICAL ARTS BLVD STE 301
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46011-3460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-298-4400
-----------------------------------------------------
Fax | 765-298-4940
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 MEDICAL ARTS BLVD STE 301
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46011-3460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-298-4400
-----------------------------------------------------
Fax | 765-298-4940
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 173
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 12012276A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 12012276B
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------