=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235215419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIN W SHAW DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 FREDERICA STREET SUITE 301
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-926-7272
-----------------------------------------------------
Fax | 270-926-2699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3014 AUTUMN LAKE COVE
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-993-4270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7760
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------