Provider Demographics
NPI:1710030697
Name:DR W SHANE HOLMES INC
Entity Type:Organization
Organization Name:DR W SHANE HOLMES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS, MDS
Authorized Official - Phone:304-343-3672
Mailing Address - Street 1:867 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2057
Mailing Address - Country:US
Mailing Address - Phone:304-343-3672
Mailing Address - Fax:304-720-3672
Practice Address - Street 1:867 OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2057
Practice Address - Country:US
Practice Address - Phone:304-343-3672
Practice Address - Fax:304-720-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4002075000Medicaid