Provider Demographics
NPI:1598331084
Name:SMITH, SHAYNE ALEXANDER (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAYNE
Middle Name:ALEXANDER
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12141 BURDETTE CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3565
Mailing Address - Country:US
Mailing Address - Phone:360-349-1662
Mailing Address - Fax:
Practice Address - Street 1:3102 E ELK LN
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-8636
Practice Address - Country:US
Practice Address - Phone:402-512-4028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE77111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice