Healthcare Provider Details

I. General information

NPI: 1972646586
Provider Name (Legal Business Name): KENNETH M. SHOU D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 QUEST DR
EUGENE OR
97402-8768
US

IV. Provider business mailing address

2941 FLINTLOCK ST
EUGENE OR
97408-4660
US

V. Phone/Fax

Practice location:
  • Phone: 541-688-7278
  • Fax: 541-334-6604
Mailing address:
  • Phone: 541-343-2624
  • Fax: 541-334-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7719
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: