=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912152943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAWNEE STATE UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2008
-----------------------------------------------------
Last Update Date | 11/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 SECOND ST. HEALTH SCIENCES DEPT.
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-351-3216
-----------------------------------------------------
Fax | 740-351-3354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 940 SECOND ST. HEALTH SCIENCES DEPT.
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-351-3216
-----------------------------------------------------
Fax | 740-351-3354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISING DENTIST - SHAWNEE STATE
-----------------------------------------------------
Name | JAMES ROGER KADEL
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 740-351-3216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30-012492
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------