=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568992022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAKAMAK FAMILY DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2017
-----------------------------------------------------
Last Update Date | 06/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 S MERIDIAN ST
-----------------------------------------------------
City | JASONVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47438-1520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-665-2275
-----------------------------------------------------
Fax | 812-665-9374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 C ST NW
-----------------------------------------------------
City | LINTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47441-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-847-8646
-----------------------------------------------------
Fax | 812-847-8761
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEVEN W KELLETT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 812-665-2275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12012106A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------