Provider Demographics
NPI:1780257451
Name:TIPPLE, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:TIPPLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 192ND ARMORED TANK BN RD
Mailing Address - Street 2:
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:968 1ST INFANTRY DIVISION RD
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5210
Practice Address - Country:US
Practice Address - Phone:502-626-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002857122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice