Provider Demographics
NPI:1205366846
Name:TRIPLE CROWN DENTISTRY
Entity Type:Organization
Organization Name:TRIPLE CROWN DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-409-4299
Mailing Address - Street 1:904 LILY CREEK ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243
Mailing Address - Country:US
Mailing Address - Phone:502-409-4299
Mailing Address - Fax:502-409-4309
Practice Address - Street 1:904 LILY CREEK ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243
Practice Address - Country:US
Practice Address - Phone:502-409-4299
Practice Address - Fax:502-409-4309
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIPLE CROWN DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY90761223G0001X
KY93051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty