Provider Demographics
NPI:1801928924
Name:SHAW, KELLY P
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5995 KUAKINI HWY STE 113
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2120
Mailing Address - Country:US
Mailing Address - Phone:808-327-0300
Mailing Address - Fax:808-327-0401
Practice Address - Street 1:75-5995 KUAKINI HWY STE 113
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2120
Practice Address - Country:US
Practice Address - Phone:808-327-0300
Practice Address - Fax:808-327-0401
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT19931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice