Provider Demographics
NPI:1124127832
Name:JAMES A SHUPE DDS, DENTISTRY FOR CHILDREN, INC
Entity type:Organization
Organization Name:JAMES A SHUPE DDS, DENTISTRY FOR CHILDREN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHUPE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-422-8419
Mailing Address - Street 1:3030 LAKE AVE
Mailing Address - Street 2:SUITE 15
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5428
Mailing Address - Country:US
Mailing Address - Phone:260-422-8419
Mailing Address - Fax:260-422-3591
Practice Address - Street 1:3030 LAKE AVE
Practice Address - Street 2:SUITE 15
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5428
Practice Address - Country:US
Practice Address - Phone:260-422-8419
Practice Address - Fax:260-422-3591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000026A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty