Provider Demographics
NPI:1174121099
Name:MADELYN SHORE, DMD, PLLC
Entity type:Organization
Organization Name:MADELYN SHORE, DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADELYN
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:336-909-5777
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28570-0309
Mailing Address - Country:US
Mailing Address - Phone:252-223-4161
Mailing Address - Fax:252-223-2442
Practice Address - Street 1:271 HOWARD BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NC
Practice Address - Zip Code:28570-7927
Practice Address - Country:US
Practice Address - Phone:252-223-4161
Practice Address - Fax:252-223-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty