Provider Demographics
NPI:1679640114
Name:SHUSTER, MYRON F (DMD)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:F
Last Name:SHUSTER
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 1:3101 BRECKENRIDGE LN
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2742
Mailing Address - Country:US
Mailing Address - Phone:502-451-1020
Mailing Address - Fax:502-451-9339
Practice Address - Street 1:3101 BRECKENRIDGE LN
Practice Address - Street 2:SUITE 4B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2742
Practice Address - Country:US
Practice Address - Phone:502-451-1020
Practice Address - Fax:502-451-9339
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4503Medicaid
KY59258OtherUCCI BRECKENRIDGE LANE
KY1377294OtherUCCI 2ND LOCATION FISCHER