Provider Demographics
NPI:1851513972
Name:SHUSTER, KEVIN MICHAEL (KEVIN SHUSTER)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:SHUSTER
Suffix:
Gender:M
Credentials:KEVIN SHUSTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1154
Mailing Address - Country:US
Mailing Address - Phone:928-776-1993
Mailing Address - Fax:928-541-1176
Practice Address - Street 1:1727 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1154
Practice Address - Country:US
Practice Address - Phone:928-776-1993
Practice Address - Fax:928-541-1176
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD39071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice