Provider Demographics
NPI:1154765899
Name:SHAW DDS DENTAL CORPORATION
Entity type:Organization
Organization Name:SHAW DDS DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-933-5641
Mailing Address - Street 1:5220 W WASHINGTON BLVD
Mailing Address - Street 2:103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-1331
Mailing Address - Country:US
Mailing Address - Phone:323-933-5641
Mailing Address - Fax:323-939-6620
Practice Address - Street 1:5220 W WASHINGTON BLVD
Practice Address - Street 2:103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016
Practice Address - Country:US
Practice Address - Phone:323-933-5641
Practice Address - Fax:323-939-6620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54813305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization