Provider Demographics
NPI:1487494795
Name:SHAHTOUT, KIERSTIN ELIZABETH (DDS)
Entity type:Individual
Prefix:
First Name:KIERSTIN
Middle Name:ELIZABETH
Last Name:SHAHTOUT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KIERSTIN
Other - Middle Name:ELIZABETH
Other - Last Name:EVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7114 SHAVER DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-8505
Mailing Address - Country:US
Mailing Address - Phone:406-788-0848
Mailing Address - Fax:
Practice Address - Street 1:2000 MAPLE ST STE 100
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-2089
Practice Address - Country:US
Practice Address - Phone:406-919-6141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-27
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-30828122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist