Provider Demographics
NPI:1366591166
Name:SHAW, THOMAS EDWARD III (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:EDWARD
Last Name:SHAW
Suffix:III
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 1:371 HICKORY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8753
Mailing Address - Country:US
Mailing Address - Phone:863-660-2316
Mailing Address - Fax:
Practice Address - Street 1:2750 WATTS DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2721
Practice Address - Country:US
Practice Address - Phone:770-429-0955
Practice Address - Fax:770-429-0219
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN93161223G0001X
GADN0095891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003155301AMedicaid
FL004102800Medicaid