Provider Demographics
NPI:1366826224
Name:HEWARD, SHAUN THOMAS (DMD, MD)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:THOMAS
Last Name:HEWARD
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5742 S 1475 E STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4857
Mailing Address - Country:US
Mailing Address - Phone:801-479-9070
Mailing Address - Fax:
Practice Address - Street 1:5742 S 1475 E STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4857
Practice Address - Country:US
Practice Address - Phone:801-479-9070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021498390200000X
UT12210727-99251223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program