Provider Demographics
NPI:1225813983
Name:SHANE M. WELLINGTON DMD LLC
Entity Type:Organization
Organization Name:SHANE M. WELLINGTON DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:WELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-385-1352
Mailing Address - Street 1:1609 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-2146
Mailing Address - Country:US
Mailing Address - Phone:330-385-1352
Mailing Address - Fax:330-385-7407
Practice Address - Street 1:1609 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2146
Practice Address - Country:US
Practice Address - Phone:330-385-1352
Practice Address - Fax:330-385-7407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty