Provider Demographics
NPI:1053446419
Name:MELVIN L SHANLEY DDS PA
Entity Type:Organization
Organization Name:MELVIN L SHANLEY DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-697-7377
Mailing Address - Street 1:4315 MOONLIGHT WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1688
Mailing Address - Country:US
Mailing Address - Phone:210-697-7377
Mailing Address - Fax:210-697-7319
Practice Address - Street 1:4315 MOONLIGHT WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1688
Practice Address - Country:US
Practice Address - Phone:210-697-7377
Practice Address - Fax:210-697-7319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX156681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1679515357OtherNPI