Provider Demographics
NPI:1467835074
Name:VAUGHN, WILLIAM SHANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:SHANE
Last Name:VAUGHN
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 1:2113 SARNO RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935
Mailing Address - Country:US
Mailing Address - Phone:321-259-9429
Mailing Address - Fax:
Practice Address - Street 1:2113 SARNO RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:321-259-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9626122300000X
FL22193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist