Provider Demographics
NPI:1649610130
Name:SHAW, KEITH BILLINGS (DMD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:BILLINGS
Last Name:SHAW
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 1:2945 ROSEBUD RD
Mailing Address - Street 2:#420
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8947
Mailing Address - Country:US
Mailing Address - Phone:208-709-8782
Mailing Address - Fax:
Practice Address - Street 1:4324 COVINGTON HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-1208
Practice Address - Country:US
Practice Address - Phone:404-289-6454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014607122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist