Provider Demographics
NPI:1972082451
Name:MCSHANE, MARK RUTLEDGE (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RUTLEDGE
Last Name:MCSHANE
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 1:618TH DENTAL COMPANY (AS),
Mailing Address - Street 2:USA DENTAC-KOREA UNIT #15660 BLDG # P 3020
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96271-5660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:618TH DENTAL COMPANY (AS),
Practice Address - Street 2:USA DENTAC-KOREA UNIT #15660 BLDG # P 3020
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5660
Practice Address - Country:US
Practice Address - Phone:315-737-9186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041813122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist