MEDICARE: JEFFREY J. SHAMBAUGH DMD PC

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	1223G0001X	General Practice Dentistry	12011943A	IN
2	1223G0001X	General Practice Dentistry	12010642A	IN

General Provider Information

NPI Number	:	1568838225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFREY J. SHAMBAUGH DMD PC

Provider Business Mailing Address
First Line	:	4341 FLAGSTAFF CV
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-4400
Country	:	US
Telephone Number	:	260-493-2432
Fax Number	:	260-492-2942

Provider Business Practice Location Address
First Line	:	4341 FLAGSTAFF CV
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-4400
Country	:	US
Telephone Number	:	260-493-2432
Fax Number	:	260-492-2942

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. JEFFREY JOSEPH SHAMBAUGH
Credential	:	DMD
Telephone Number	:	260-493-2432

Provider Enumeration Date	:	08/18/2015
Last Update Date	:	08/18/2015

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