Provider Demographics
NPI:1811334857
Name:MATTOX, SHAYNA L (DDS)
Entity type:Individual
Prefix:
First Name:SHAYNA
Middle Name:L
Last Name:MATTOX
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SHAYNA
Other - Middle Name:
Other - Last Name:GARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18328 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-1773
Mailing Address - Country:US
Mailing Address - Phone:402-319-6688
Mailing Address - Fax:
Practice Address - Street 1:10520 S 204TH ST STE C
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-4185
Practice Address - Country:US
Practice Address - Phone:402-403-6007
Practice Address - Fax:402-403-1243
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE76431223P0221X
OH30.0253581223P0221X
OHRES.003928122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0337241Medicaid
NE10028122905Medicaid