Provider Demographics
NPI:1235215419
Name:SHAW, KIN W (DMD)
Entity Type:Individual
Prefix:
First Name:KIN
Middle Name:W
Last Name:SHAW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 AUTUMN LAKE COVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303
Mailing Address - Country:US
Mailing Address - Phone:270-993-4270
Mailing Address - Fax:
Practice Address - Street 1:920 FREDERICA STREET
Practice Address - Street 2:SUITE 301
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301
Practice Address - Country:US
Practice Address - Phone:270-926-7272
Practice Address - Fax:270-926-2699
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60001476Medicaid