Provider Demographics
NPI:1508901166
Name:COUCH HOLLIDAY, SHANNA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNA
Middle Name:
Last Name:COUCH HOLLIDAY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 DOCTORS ROW
Mailing Address - Street 2:
Mailing Address - City:CHAVIES
Mailing Address - State:KY
Mailing Address - Zip Code:41727-8954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 MORTON BLVD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9470
Practice Address - Country:US
Practice Address - Phone:606-439-1079
Practice Address - Fax:606-439-3878
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY76331223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000262Medicaid
KY45003811Medicaid