Provider Demographics
NPI:1699040592
Name:SHAW DENTAL, LLC
Entity Type:Organization
Organization Name:SHAW DENTAL, LLC
Other - Org Name:MINDY SHAW, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-789-0619
Mailing Address - Street 1:2247 JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-8050
Mailing Address - Country:US
Mailing Address - Phone:907-789-0619
Mailing Address - Fax:907-789-7004
Practice Address - Street 1:2247 JORDAN AVE
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-8050
Practice Address - Country:US
Practice Address - Phone:907-789-0619
Practice Address - Fax:907-789-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK13411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty