Provider Demographics
NPI:1699980607
Name:SHAMBAUGH, MICHAEL EUGENE (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EUGENE
Last Name:SHAMBAUGH
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 1:1320 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5844
Mailing Address - Country:US
Mailing Address - Phone:260-484-7919
Mailing Address - Fax:260-484-5259
Practice Address - Street 1:1320 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5844
Practice Address - Country:US
Practice Address - Phone:260-484-7919
Practice Address - Fax:260-484-5259
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009044A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice