Provider Demographics
NPI:1801176136
Name:COUNTRYMAN, SHAWN C (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:C
Last Name:COUNTRYMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 PINION DR
Mailing Address - Street 2:
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-335-9886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-9870122300000X, 1223X0008X
CO002051671223X0008X
IA30418390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program