Provider Demographics
NPI:1528464781
Name:SHUTE, JILLIAN LAVERNE (DDS)
Entity type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:LAVERNE
Last Name:SHUTE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:US DENTAC HEALTH ACTIVITY FORT CAVAZOS
Mailing Address - Street 2:36000 SHOEMAKER LANE, SUITE 1051
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5054
Mailing Address - Country:US
Mailing Address - Phone:785-239-7927
Mailing Address - Fax:
Practice Address - Street 1:US DENTAC HEALTH ACTIVITY FORT CAVAZOS
Practice Address - Street 2:36000 SHOEMAKER LANE, SUITE 1051
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544-5054
Practice Address - Country:US
Practice Address - Phone:254-287-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32580122300000X, 1223X0400X
CA635581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice