Provider Demographics
NPI:1033409834
Name:SHAW, ITIEN EMILY (DDS, MD)
Entity Type:Individual
Prefix:
First Name:ITIEN
Middle Name:EMILY
Last Name:SHAW
Suffix:
Gender:F
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 TRUXEL RD STE C
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-3758
Mailing Address - Country:US
Mailing Address - Phone:844-673-9131
Mailing Address - Fax:916-419-4582
Practice Address - Street 1:4170 TRUXEL RD STE C
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-3758
Practice Address - Country:US
Practice Address - Phone:844-673-9131
Practice Address - Fax:916-419-4582
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
CADDS1028371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty