MEDICARE: DR. SCOTT WILLIAM SHALLISH D.M.D.

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	055055	NY

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	:	1780812123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT WILLIAM SHALLISH D.M.D.

Provider Business Mailing Address
First Line	:	3930 E GENESEE ST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13214-1934
Country	:	US
Telephone Number	:	315-471-6188
Fax Number	:	315-471-0271

Provider Business Practice Location Address
First Line	:	3930 E GENESEE ST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13214-1934
Country	:	US
Telephone Number	:	315-471-6188
Fax Number	:	315-471-0271

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

Provider Enumeration Date	:	06/24/2009
Last Update Date	:	01/04/2012

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