Provider Demographics
NPI:1871724914
Name:OWENSBORO CENTER FOR ORAL & MAXILLOFACIAL SURGERY, PLLC
Entity type:Organization
Organization Name:OWENSBORO CENTER FOR ORAL & MAXILLOFACIAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:SHAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-926-6100
Mailing Address - Street 1:2816 VEACH RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-6295
Mailing Address - Country:US
Mailing Address - Phone:270-926-6100
Mailing Address - Fax:270-926-6195
Practice Address - Street 1:2816 VEACH RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-6295
Practice Address - Country:US
Practice Address - Phone:270-926-6100
Practice Address - Fax:270-926-6195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64046378Medicaid
1033220280OtherNPI
KYT54036Medicare UPIN
KY64046378Medicaid