Provider Demographics
NPI:1225489735
Name:THOMAS, SHANE MATHEW (DDS)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MATHEW
Last Name:THOMAS
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 1:2002 MAPLERIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-2747
Mailing Address - Country:US
Mailing Address - Phone:586-925-1346
Mailing Address - Fax:
Practice Address - Street 1:15055 22 MILE RD STE 200
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4401
Practice Address - Country:US
Practice Address - Phone:586-247-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist