Provider Demographics
NPI:1871765321
Name:SHAW, JEFFREY S (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:SHAW
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 1:1681 AMBERWOOD DR APT 207
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-1916
Mailing Address - Country:US
Mailing Address - Phone:323-633-4536
Mailing Address - Fax:
Practice Address - Street 1:3311 GLENDALE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1812
Practice Address - Country:US
Practice Address - Phone:323-665-7665
Practice Address - Fax:323-953-6695
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA532731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice