Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 007624 | CT |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 007624 | CT |
NPI | 1528065992 |
---|---|
Provider Name | David Shafer |
First Address | Farmington, CT 06030-2212 |
Second Address | Farmington, CT 06030-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2005 |
Last Update Date | 12/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
002076249 | (05) | CT |
U28046 | (02) | CT |