Healthcare Provider Details

I. General information

NPI: 1568346674
Provider Name (Legal Business Name): ANNELISE SHAW DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 MEDICAL CENTER RD
APO AA
76544-5060
US

IV. Provider business mailing address

403 ROSEDALE BLVD
GEORGETOWN TX
78628-4675
US

V. Phone/Fax

Practice location:
  • Phone: 310-989-0323
  • Fax:
Mailing address:
  • Phone: 310-989-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12913
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: