Provider Demographics
NPI:1891469664
Name:MCSHANE, MITCHELL BRIAN (DMD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:BRIAN
Last Name:MCSHANE
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 1:901 BIESTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VLG
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3392
Mailing Address - Country:US
Mailing Address - Phone:847-437-8366
Mailing Address - Fax:
Practice Address - Street 1:901 BIESTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VLG
Practice Address - State:IL
Practice Address - Zip Code:60007-3392
Practice Address - Country:US
Practice Address - Phone:847-437-8366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist