Healthcare Provider Details

I. General information

NPI: 1073444147
Provider Name (Legal Business Name): RHETT SHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 BUSINESS PARK DR
CHINO VALLEY AZ
86323-5765
US

IV. Provider business mailing address

328 BUSINESS PARK DR
CHINO VALLEY AZ
86323-5765
US

V. Phone/Fax

Practice location:
  • Phone: 928-636-6872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012807
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: