Provider Demographics
NPI:1689019945
Name:SHANEAN MICHELLE ANDERSON DDS PA
Entity Type:Organization
Organization Name:SHANEAN MICHELLE ANDERSON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANEAN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-825-1795
Mailing Address - Street 1:900 S FRANKLIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2799
Mailing Address - Country:US
Mailing Address - Phone:919-825-1795
Mailing Address - Fax:919-229-8483
Practice Address - Street 1:900 S FRANKLIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2799
Practice Address - Country:US
Practice Address - Phone:919-825-1795
Practice Address - Fax:919-229-8483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8755122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty