Provider Demographics
NPI:1568346674
Name:SHAW, ANNELISE (DMD)
Entity type:Individual
Prefix:
First Name:ANNELISE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S GATEWAY PLAZA BLVD UNIT 1401
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-2779
Mailing Address - Country:US
Mailing Address - Phone:310-989-0323
Mailing Address - Fax:
Practice Address - Street 1:2441 21ST ST
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5582
Practice Address - Country:US
Practice Address - Phone:270-798-8751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-01
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist