Provider Demographics
NPI:1659568178
Name:GOSLINGA, SHANE NELIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:NELIS
Last Name:GOSLINGA
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 1:5929 NW 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-4253
Mailing Address - Country:US
Mailing Address - Phone:352-316-0003
Mailing Address - Fax:
Practice Address - Street 1:5929 NW 43RD AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-4253
Practice Address - Country:US
Practice Address - Phone:352-316-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL170711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice