Provider Demographics
NPI:1013427509
Name:LDSHANE PLLC
Entity Type:Organization
Organization Name:LDSHANE PLLC
Other - Org Name:NORTH JACKSONVILLE COMPLETE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-751-4958
Mailing Address - Street 1:1566 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218
Mailing Address - Country:US
Mailing Address - Phone:904-751-4958
Mailing Address - Fax:904-751-5330
Practice Address - Street 1:1566 DUNN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218
Practice Address - Country:US
Practice Address - Phone:904-751-4958
Practice Address - Fax:904-751-5330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty