Provider Demographics
NPI:1467835462
Name:SHAW, KATIE ANN (RDH)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:SHAW
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 CHEMAWA RD NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1119
Mailing Address - Country:US
Mailing Address - Phone:541-212-1725
Mailing Address - Fax:
Practice Address - Street 1:3750 CHEMAWA RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1119
Practice Address - Country:US
Practice Address - Phone:541-212-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7001124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist