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General NPI Number Information
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NPI Number | 1326215005
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Entity Type | Organization
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Legal Business Name | SDSDDS, LLC
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Dates
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Enumeration Date | 05/13/2008
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Last Update Date | 05/13/2008
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Provider Practice Location Address
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Address Line | 1850 GRAND PORTAGE TRL
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City | XENIA
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State | OH
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Zip | 45385-9593
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Country | US
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Telephone | 937-369-3069
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Fax | 937-431-1268
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Provider Business Mailing Address
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Address Line | 1850 GRAND PORTAGE TRL
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City | XENIA
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State | OH
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Zip | 45385-9593
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Country | US
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Telephone | 937-369-3069
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Fax | 937-431-1268
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Authorized Official
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Title or Position | SINGLE MEMBER
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Name | DR. STEVE D SHUFFLEBARGER
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Credential | DDS
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Telephone | 937-369-3069
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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 | 30021080
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License Number State | OH
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