Provider Demographics
NPI:1265630214
Name:MC DONOUGH, SHAELAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHAELAN
Middle Name:
Last Name:MC DONOUGH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 N MOORPARK RD STE B
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3732
Mailing Address - Country:US
Mailing Address - Phone:702-205-5398
Mailing Address - Fax:805-494-5322
Practice Address - Street 1:593 N MOORPARK RD STE B
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3732
Practice Address - Country:US
Practice Address - Phone:702-205-5398
Practice Address - Fax:805-494-5322
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56210122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NED7298Medicaid