Provider Demographics
NPI:1851318687
Name:SHANE, CARRIE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:A
Last Name:SHANE
Suffix:
Gender:F
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:PO BOX 5956
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5956
Mailing Address - Country:US
Mailing Address - Phone:360-676-6177
Mailing Address - Fax:360-527-8778
Practice Address - Street 1:220 UNITY ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4429
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:360-527-8778
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008040122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5028048Medicaid