Provider Demographics
NPI:1033651427
Name:SHANE DAVIDSON DDS PC
Entity Type:Organization
Organization Name:SHANE DAVIDSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-977-3006
Mailing Address - Street 1:5574 COOLEY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-3015
Mailing Address - Country:US
Mailing Address - Phone:248-977-3006
Mailing Address - Fax:
Practice Address - Street 1:5574 COOLEY LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-3015
Practice Address - Country:US
Practice Address - Phone:248-977-3006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANE DAVIDSON DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020222122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901020222Medicaid