Provider Demographics
NPI:1790098937
Name:VAN CLEAVE, SHANA LORELLE (DDS)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:LORELLE
Last Name:VAN CLEAVE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:BERGER
Other - Last Name:VAN CLEAVE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4655 HOEN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7830
Mailing Address - Country:US
Mailing Address - Phone:707-546-5437
Mailing Address - Fax:
Practice Address - Street 1:4655 HOEN AVE STE 1
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7830
Practice Address - Country:US
Practice Address - Phone:707-546-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA592381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry