Provider Demographics
NPI:1174100903
Name:GHODS, SHAWN (DMD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:
Last Name:GHODS
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 1:5311 NW TORINO LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3239
Mailing Address - Country:US
Mailing Address - Phone:571-442-4884
Mailing Address - Fax:
Practice Address - Street 1:1130 SW ST LUCIE W BLVD
Practice Address - Street 2:SUITE #206
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986
Practice Address - Country:US
Practice Address - Phone:772-807-1451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist