Provider Demographics
NPI:1376160010
Name:MCTIERNAN, SHANE ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ROBERT
Last Name:MCTIERNAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10020 INVENTION LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-4093
Mailing Address - Country:US
Mailing Address - Phone:570-687-0798
Mailing Address - Fax:
Practice Address - Street 1:651 NAUTICA DR UNIT 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7222
Practice Address - Country:US
Practice Address - Phone:904-423-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK79681223G0001X
FLDN250091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice