Provider Demographics
NPI:1336211010
Name:HOLMES, W. SHANE (DDS,MDS)
Entity Type:Individual
Prefix:DR
First Name:W.
Middle Name:SHANE
Last Name:HOLMES
Suffix:
Gender:M
Credentials:DDS,MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2057
Mailing Address - Country:US
Mailing Address - Phone:304-343-3672
Mailing Address - Fax:304-720-3672
Practice Address - Street 1:867 OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2057
Practice Address - Country:US
Practice Address - Phone:304-343-3672
Practice Address - Fax:304-720-3672
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4002075000Medicaid