MEDICARE: THE SMILE SHOP INC

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	122300000X	Dentist	3627	KY

General Provider Information

NPI Number	:	1336224484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SMILE SHOP INC

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

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT B SHACKLETTE
Credential	:	DMD
Telephone Number	:	859-223-7300

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	08/22/2020

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