=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972819654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W.H. SHUTTLESWORTH D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2010
-----------------------------------------------------
Last Update Date | 08/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4301 RETAMA CIR
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-578-9031
-----------------------------------------------------
Fax | 361-572-3744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4301 RETAMA CIR
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-578-9031
-----------------------------------------------------
Fax | 361-572-3744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM H. SHUTTLESWORTH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 361-578-9031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 11133
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------