=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740648120
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWN HANWAY DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2016
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2304 KILLEARN CENTER BLVD
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32309-3580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-666-5365
-----------------------------------------------------
Fax | 888-977-0344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1395 CENTER DR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32610-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN20666
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------