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General NPI Number Information
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NPI Number | 1295949444
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Entity Type | Organization
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Legal Business Name | RODERICK K SHAW III DMD PA
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 255 NE DUVAL AVE
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City | MADISON
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State | FL
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Zip | 32340
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Country | US
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Telephone | 850-973-6427
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Fax | 850-973-9646
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Provider Business Mailing Address
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Address Line | 255 NE DUVAL AVE
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City | MADISON
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State | FL
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Zip | 32340
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Country | US
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Telephone | 850-973-6427
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Fax | 850-973-9646
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Authorized Official
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Title or Position | VICE PRES
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Name | DR. KATHLEEN B SHAW
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Credential | DM
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Telephone | 850-973-6427
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN10977
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License Number State | FL
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