Provider Demographics
NPI:1801516828
Name:SHAW, MICAH MICHELLE (DMD)
Entity type:Individual
Prefix:DR
First Name:MICAH
Middle Name:MICHELLE
Last Name:SHAW
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 EL PRADO AVE
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-4310
Mailing Address - Country:US
Mailing Address - Phone:519-980-9721
Mailing Address - Fax:
Practice Address - Street 1:1422 EL PRADO AVE
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-4310
Practice Address - Country:US
Practice Address - Phone:619-980-9721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist