Provider Demographics
NPI:1619942083
Name:NELSON, SHANE AARON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:AARON
Last Name:NELSON
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 1:14973 OUTLOOK LN
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-2931
Mailing Address - Country:US
Mailing Address - Phone:913-302-1478
Mailing Address - Fax:913-897-9505
Practice Address - Street 1:7001 W 121ST ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2009
Practice Address - Country:US
Practice Address - Phone:913-313-8428
Practice Address - Fax:913-906-0800
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19850122300000X
MO2016000952122300000X
KS71171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist