Provider Demographics
NPI:1205361862
Name:SHANE DENTAL LLC
Entity Type:Organization
Organization Name:SHANE DENTAL LLC
Other - Org Name:SHANE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-386-2133
Mailing Address - Street 1:108 WALNUT ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-4501
Mailing Address - Country:US
Mailing Address - Phone:715-386-2133
Mailing Address - Fax:
Practice Address - Street 1:108 WALNUT ST UNIT A
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-4501
Practice Address - Country:US
Practice Address - Phone:715-386-2133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100148715122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty