Provider Demographics
NPI:1184998866
Name:SHAW & WIEDERHOLD PSC
Entity type:Organization
Organization Name:SHAW & WIEDERHOLD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-926-7272
Mailing Address - Street 1:920 FREDERICA ST
Mailing Address - Street 2:301
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-3050
Mailing Address - Country:US
Mailing Address - Phone:270-926-7272
Mailing Address - Fax:
Practice Address - Street 1:920 FREDERICA ST
Practice Address - Street 2:301
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-3050
Practice Address - Country:US
Practice Address - Phone:270-926-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty