Provider Demographics
NPI:1548620560
Name:MYRON F SHUSTER DMD PSC
Entity type:Organization
Organization Name:MYRON F SHUSTER DMD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-451-1020
Mailing Address - Street 1:3101 BRECKENRIDGE LN STE 4B
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2797
Mailing Address - Country:US
Mailing Address - Phone:502-451-1020
Mailing Address - Fax:
Practice Address - Street 1:3101 BRECKENRIDGE LN STE 4B
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2797
Practice Address - Country:US
Practice Address - Phone:502-451-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60046398Medicaid