Provider Demographics
NPI:1508307778
Name:MCSHANE, MATTHEW JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:MCSHANE
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 1:3340 N LAWNDALE AVE # 3N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5326
Mailing Address - Country:US
Mailing Address - Phone:630-788-8374
Mailing Address - Fax:
Practice Address - Street 1:901 BIESTERFIELD RD STE 104
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3393
Practice Address - Country:US
Practice Address - Phone:847-437-8366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0311641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice