Provider Demographics
NPI:1801201892
Name:ECKELS, SHANE K (DMD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:K
Last Name:ECKELS
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 1:926 GREAT POND DR STE 2002
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:926 GREAT POND DR STE 1000
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-7244
Practice Address - Country:US
Practice Address - Phone:407-862-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 207391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice