Provider Demographics
NPI:1215932504
Name:SHALL, STEPHEN MARK (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:SHALL
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 1:5690 MONROE ST
Mailing Address - Street 2:STE A
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2736
Mailing Address - Country:US
Mailing Address - Phone:419-479-3939
Mailing Address - Fax:419-479-3933
Practice Address - Street 1:5690 MONROE ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2736
Practice Address - Country:US
Practice Address - Phone:419-479-3939
Practice Address - Fax:419-479-3933
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166341223S0112X
OH30.016634204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0515599Medicaid
OHSH0504572Medicare ID - Type UnspecifiedSTEPHEN M. SHALL
OHT47412Medicare UPIN