MEDICARE: DR. KENNETH DEMETRIC SHUMATE D.D.S

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	14944	MD
3	1223G0001X	General Practice Dentistry	0401413457	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417236613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH DEMETRIC SHUMATE D.D.S

Provider Business Mailing Address
First Line	:	3010 CRAIN HWY
Second Line	:	SUITE 202
City	:	WALDORF
State	:	MD
Zip	:	20601-2801
Country	:	US
Telephone Number	:	240-518-8928
Fax Number	:	240-518-8931

Provider Business Practice Location Address
First Line	:	3010 CRAIN HWY
Second Line	:	SUITE 202
City	:	WALDORF
State	:	MD
Zip	:	20601-2801
Country	:	US
Telephone Number	:	240-518-8928
Fax Number	:	240-518-8931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2011
Last Update Date	:	08/08/2016

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