Provider Demographics
NPI:1457553265
Name:SHAW, KIM LESLIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:LESLIE
Last Name:SHAW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S OSPREY AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-3512
Mailing Address - Country:US
Mailing Address - Phone:941-366-8511
Mailing Address - Fax:941-366-3516
Practice Address - Street 1:1872 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-493-6363
Practice Address - Fax:941-493-6363
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-00124631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice