Provider Demographics
NPI:1710324132
Name:SHANEYFELT, MARK EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:SHANEYFELT
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 1:422 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-3456
Mailing Address - Country:US
Mailing Address - Phone:406-222-0636
Mailing Address - Fax:406-222-0636
Practice Address - Street 1:422 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3456
Practice Address - Country:US
Practice Address - Phone:406-222-0636
Practice Address - Fax:406-222-0636
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-79001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice