Provider Demographics
NPI:1255345039
Name:MOORE, SHAWN LEE (DMD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:LEE
Last Name:MOORE
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 1:4544 TAYLORSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-3528
Mailing Address - Country:US
Mailing Address - Phone:502-499-0442
Mailing Address - Fax:502-499-0434
Practice Address - Street 1:4544 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-3528
Practice Address - Country:US
Practice Address - Phone:502-499-0442
Practice Address - Fax:502-499-0434
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY74781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice