Provider Demographics
NPI:1457847667
Name:SHAW, KELLY (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 DAIRY LN APT A
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-9766
Mailing Address - Country:US
Mailing Address - Phone:304-680-0735
Mailing Address - Fax:
Practice Address - Street 1:1151 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWELL
Practice Address - State:WV
Practice Address - Zip Code:26050-1437
Practice Address - Country:US
Practice Address - Phone:304-459-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV43521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice