Provider Demographics
NPI:1134334907
Name:SHAW, COLIN SIMEON (DMD)
Entity type:Individual
Prefix:DR
First Name:COLIN
Middle Name:SIMEON
Last Name:SHAW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 JEFFERSON LN NE STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2120
Mailing Address - Country:US
Mailing Address - Phone:505-888-3395
Mailing Address - Fax:505-888-3426
Practice Address - Street 1:4620 JEFFERSON LN NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2120
Practice Address - Country:US
Practice Address - Phone:505-888-3395
Practice Address - Fax:505-888-3426
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD15631223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics