Provider Demographics
NPI:1629964531
Name:SHUMARD, KALEB BLAINE (DMD)
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:BLAINE
Last Name:SHUMARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4574 NICKLAUS CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-9315
Mailing Address - Country:US
Mailing Address - Phone:217-259-5660
Mailing Address - Fax:
Practice Address - Street 1:1353 E MOUND RD STE 102
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3676
Practice Address - Country:US
Practice Address - Phone:217-877-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190361051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice