Provider Demographics
NPI:1568838225
Name:JEFFREY J. SHAMBAUGH DMD PC
Entity type:Organization
Organization Name:JEFFREY J. SHAMBAUGH DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SHAMBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:260-493-2432
Mailing Address - Street 1:4341 FLAGSTAFF CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4400
Mailing Address - Country:US
Mailing Address - Phone:260-493-2432
Mailing Address - Fax:260-492-2942
Practice Address - Street 1:4341 FLAGSTAFF CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4400
Practice Address - Country:US
Practice Address - Phone:260-493-2432
Practice Address - Fax:260-492-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010642A1223G0001X
IN12011943A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty