Provider Demographics
NPI:1225443336
Name:DREW, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:DREW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 N TREKELL RD STE 9
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-1705
Mailing Address - Country:US
Mailing Address - Phone:520-374-2400
Mailing Address - Fax:
Practice Address - Street 1:1821 N TREKELL RD STE 9
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1705
Practice Address - Country:US
Practice Address - Phone:520-374-2400
Practice Address - Fax:520-836-7469
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60477540122300000X
AZD0114621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty