Provider Demographics
NPI:1376160010
Name:MCTIERNAN, SHANE ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ROBERT
Last Name:MCTIERNAN
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 1:1242 N 16TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-5006
Mailing Address - Country:US
Mailing Address - Phone:570-687-0798
Mailing Address - Fax:
Practice Address - Street 1:463859 STATE ROAD 200
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3639
Practice Address - Country:US
Practice Address - Phone:904-335-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN250091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice