=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669601027
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHA TAO DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2009
-----------------------------------------------------
Last Update Date | 08/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4670 MCDERMOTT RD STE 200
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024-7791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-335-5455
-----------------------------------------------------
Fax | 972-335-2040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4670 MCDERMOTT RD. #200
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-335-5455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 24795
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------