MEDICARE: SDSDDS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	30021080	OH

General Provider Information

NPI Number	:	1326215005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SDSDDS, LLC

Provider Business Mailing Address
First Line	:	1850 GRAND PORTAGE TRL
Second Line	:
City	:	XENIA
State	:	OH
Zip	:	45385-9593
Country	:	US
Telephone Number	:	937-369-3069
Fax Number	:	937-431-1268

Provider Business Practice Location Address
First Line	:	1850 GRAND PORTAGE TRL
Second Line	:
City	:	XENIA
State	:	OH
Zip	:	45385-9593
Country	:	US
Telephone Number	:	937-369-3069
Fax Number	:	937-431-1268

Authorized Official
Title or Position	:	SINGLE MEMBER
Name	:	DR. STEVE D SHUFFLEBARGER
Credential	:	DDS
Telephone Number	:	937-369-3069

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	05/13/2008

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