Provider Demographics
NPI:1720130289
Name:FALLER-SHACKLETON, NANCY MARIE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:MARIE
Last Name:FALLER-SHACKLETON
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 PRESTON HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1716
Mailing Address - Country:US
Mailing Address - Phone:502-637-2900
Mailing Address - Fax:502-637-2425
Practice Address - Street 1:3019 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1716
Practice Address - Country:US
Practice Address - Phone:502-637-2900
Practice Address - Fax:502-637-2425
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY65431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics