Provider Demographics
NPI:1396162020
Name:SHAW FAMILY DENTAL SC
Entity type:Organization
Organization Name:SHAW FAMILY DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-425-6081
Mailing Address - Street 1:501 W. LUCAS LANE
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011
Mailing Address - Country:US
Mailing Address - Phone:715-273-3700
Mailing Address - Fax:715-273-1700
Practice Address - Street 1:501 W. LUCAS LANE
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011
Practice Address - Country:US
Practice Address - Phone:715-273-3700
Practice Address - Fax:715-273-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5175-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty