Provider Demographics
NPI:1134493893
Name:WILLIAM E SHORES JR PSC
Entity Type:Organization
Organization Name:WILLIAM E SHORES JR PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHORES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-273-2224
Mailing Address - Street 1:3122 CUSTER DR
Mailing Address - Street 2:STE B
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4000
Mailing Address - Country:US
Mailing Address - Phone:859-273-2224
Mailing Address - Fax:859-273-3725
Practice Address - Street 1:3122 CUSTER DR
Practice Address - Street 2:STE B
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4000
Practice Address - Country:US
Practice Address - Phone:859-273-2224
Practice Address - Fax:859-273-3725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60057072Medicaid