Provider Demographics
NPI:1730219239
Name:SHAW, KRISAN (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISAN
Middle Name:
Last Name:SHAW
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:PO BOX 310
Mailing Address - Street 2:501 W. LUCAS LANE
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011
Mailing Address - Country:US
Mailing Address - Phone:715-273-3700
Mailing Address - Fax:715-273-1700
Practice Address - Street 1:501 W. LUCAS LANE
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011
Practice Address - Country:US
Practice Address - Phone:715-273-3700
Practice Address - Fax:715-273-1700
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5175-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice