MEDICARE: DR. SOLITAIRE SHACKLETTE WIX DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7839	KY

General Provider Information

NPI Number	:	1134398019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SOLITAIRE SHACKLETTE WIX DMD

Provider Business Mailing Address
First Line	:	3650 BOSTON RD
Second Line	:	SUITE K
City	:	LEXINGTON
State	:	KY
Zip	:	40514-1569
Country	:	US
Telephone Number	:	859-223-7300
Fax Number	:	859-223-1122

Provider Business Practice Location Address
First Line	:	3650 BOSTON RD
Second Line	:	SUITE K
City	:	LEXINGTON
State	:	KY
Zip	:	40514-1569
Country	:	US
Telephone Number	:	859-223-7300
Fax Number	:	859-223-1122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2008
Last Update Date	:	02/26/2008

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