Provider Demographics
NPI:1174045306
Name:ONE STOP SMILE SHOP LLC
Entity Type:Organization
Organization Name:ONE STOP SMILE SHOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELBURNE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-902-6120
Mailing Address - Street 1:1477 BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40071-9009
Mailing Address - Country:US
Mailing Address - Phone:502-902-6120
Mailing Address - Fax:
Practice Address - Street 1:1477 BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40071-9009
Practice Address - Country:US
Practice Address - Phone:502-902-6120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental