Provider Demographics
NPI:1831715044
Name:SHAW, MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
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 1:841 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5262
Mailing Address - Country:US
Mailing Address - Phone:215-285-1174
Mailing Address - Fax:
Practice Address - Street 1:1500 HORIZON DR STE 104
Practice Address - Street 2:
Practice Address - City:CHALFONT
Practice Address - State:PA
Practice Address - Zip Code:18914-3966
Practice Address - Country:US
Practice Address - Phone:215-997-9980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist