Provider Demographics
NPI:1720430473
Name:KINNEY, SHAWN (DMD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:
Last Name:KINNEY
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:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-1689
Mailing Address - Country:US
Mailing Address - Phone:260-479-5853
Mailing Address - Fax:
Practice Address - Street 1:522 W FINNIE FLAT RD STE J
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7265
Practice Address - Country:US
Practice Address - Phone:928-567-5249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QD0000X
AZD0094951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental