=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598906125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN SHADA RDH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2009
-----------------------------------------------------
Last Update Date | 03/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9197 GRANT ST
-----------------------------------------------------
City | THORNTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80229-4361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-358-6092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11470 PARIS ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80640-7614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-358-6092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. SUSAN MARIE SHADA
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 303-358-6092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 903675
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------