Provider Demographics
NPI:1700538907
Name:MATT MCSHANE DDS PLLC
Entity Type:Organization
Organization Name:MATT MCSHANE DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCSHANE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-747-1967
Mailing Address - Street 1:1419 E CENTERTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-7050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1419 E CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-7050
Practice Address - Country:US
Practice Address - Phone:479-224-2361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty