Provider Demographics
NPI:1073642013
Name:SHEPHERD LANE DENTAL ASSOCIATES,P.C
Entity Type:Organization
Organization Name:SHEPHERD LANE DENTAL ASSOCIATES,P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLANEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-279-0900
Mailing Address - Street 1:3434 TOWNE CROSSING BLVD.
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2724
Mailing Address - Country:US
Mailing Address - Phone:972-286-5711
Mailing Address - Fax:972-286-6106
Practice Address - Street 1:3434 TOWNE CROSSING BLVD.
Practice Address - Street 2:SUITE 106
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2724
Practice Address - Country:US
Practice Address - Phone:972-279-0900
Practice Address - Fax:972-286-6106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091321202Medicaid