Provider Demographics
NPI:1548869878
Name:SHAHEEN, MIRAM (DDS)
Entity type:Individual
Prefix:DR
First Name:MIRAM
Middle Name:
Last Name:SHAHEEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MARSHALL ST UNIT 128
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3618
Mailing Address - Country:US
Mailing Address - Phone:502-572-9251
Mailing Address - Fax:
Practice Address - Street 1:600 MARSHALL ST UNIT 128
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3618
Practice Address - Country:US
Practice Address - Phone:502-572-9251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10256122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYS19259185OtherDRIVER'S LICENSE