=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831453869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM DEAN SHATTUCK D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2012
-----------------------------------------------------
Last Update Date | 04/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 295 FM 156 S. SUITE 200
-----------------------------------------------------
City | HASLET
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-439-8393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14208 TIJUANA TRL
-----------------------------------------------------
City | HASLET
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76052-4894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-934-9287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6430
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 31589
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------