Provider Demographics
NPI:1437315272
Name:WILLIAMS, SHANE ANTHONY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ANTHONY
Last Name:WILLIAMS
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 1:1938 LYDA AVENUE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104
Mailing Address - Country:US
Mailing Address - Phone:270-783-0064
Mailing Address - Fax:270-901-1997
Practice Address - Street 1:1802 ROCKINGHAM AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3348
Practice Address - Country:US
Practice Address - Phone:270-783-0064
Practice Address - Fax:270-901-1997
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY99431223P0106X, 1223S0112X
OK3321223S0112X
TN94221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528342Medicaid