Provider Demographics
NPI:1619049962
Name:NEWTON, SHANE LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:LEE
Last Name:NEWTON
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 1:307 E PARK ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3863
Mailing Address - Country:US
Mailing Address - Phone:208-634-5255
Mailing Address - Fax:208-634-1047
Practice Address - Street 1:307 E PARK ST STE 103
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3863
Practice Address - Country:US
Practice Address - Phone:208-634-5255
Practice Address - Fax:208-634-1047
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807401600Medicaid