Provider Demographics
NPI:1962498519
Name:TEWIS, SHANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:TEWIS
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 1:530 PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7915
Mailing Address - Country:US
Mailing Address - Phone:918-245-8333
Mailing Address - Fax:918-245-8338
Practice Address - Street 1:530 PLAZA CT
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7915
Practice Address - Country:US
Practice Address - Phone:918-245-8333
Practice Address - Fax:918-245-8338
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100126450AMedicaid