Provider Demographics
NPI:1891871471
Name:MICHAEL G SHANE DDS PC
Entity Type:Organization
Organization Name:MICHAEL G SHANE DDS PC
Other - Org Name:MICHAEL G SHANE DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:SHANE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-332-3181
Mailing Address - Street 1:350 GARFIELD
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3124
Mailing Address - Country:US
Mailing Address - Phone:307-332-3181
Mailing Address - Fax:307-332-3484
Practice Address - Street 1:350 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3124
Practice Address - Country:US
Practice Address - Phone:307-332-3181
Practice Address - Fax:307-332-3484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty