Provider Demographics
NPI:1093380420
Name:SIMPSON, SHANE ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ANTHONY
Last Name:SIMPSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7211 FAIRWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-1941
Mailing Address - Country:US
Mailing Address - Phone:864-328-5429
Mailing Address - Fax:
Practice Address - Street 1:13171 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-7805
Practice Address - Country:US
Practice Address - Phone:352-596-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25842122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist