Provider Demographics
NPI:1922012038
Name:SHANE, NICOLAS J (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:J
Last Name:SHANE
Suffix:
Gender:M
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:N79W14756 APPLETON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4376
Mailing Address - Country:US
Mailing Address - Phone:262-251-2010
Mailing Address - Fax:262-251-5690
Practice Address - Street 1:N79W14756 APPLETON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4376
Practice Address - Country:US
Practice Address - Phone:262-251-2010
Practice Address - Fax:262-251-5690
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000948-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice