Provider Demographics
NPI:1750499729
Name:SHAFER, KATHY JO (DMD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:JO
Last Name:SHAFER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3162 TRAYLOR TRL
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-4559
Mailing Address - Country:US
Mailing Address - Phone:217-622-5137
Mailing Address - Fax:
Practice Address - Street 1:3162 TRAYLOR TRL
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-4559
Practice Address - Country:US
Practice Address - Phone:217-622-5137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190213771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice