Provider Demographics
NPI:1134672611
Name:SAMANTHA SHAVER DMD PSC
Entity type:Organization
Organization Name:SAMANTHA SHAVER DMD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-968-1412
Mailing Address - Street 1:7926 PRESTON HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-3848
Mailing Address - Country:US
Mailing Address - Phone:502-968-1412
Mailing Address - Fax:502-968-8797
Practice Address - Street 1:7926 PRESTON HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-968-1412
Practice Address - Fax:502-968-8797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-01
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6937122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty