Healthcare Provider Details

I. General information

NPI: 1922299387
Provider Name (Legal Business Name): BRIAN SPENCER SHUMWAY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SCHOOL OF DENTISTRY 501 SOUTH PRESTON STREET FACULTY PRACTICE, SUITE 334
LOUISVILLE KY
40292-0001
US

IV. Provider business mailing address

SCHOOL OF DENTISTRY 501 PRESTON STREET SURGICAL AND HOSPITAL DENTISTRY RM 337
LOUISVILLE KY
40292-0001
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-5401
  • Fax: 502-852-7602
Mailing address:
  • Phone: 502-852-5083
  • Fax: 502-852-5988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number8548
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: