MEDICARE: SHANE TEWIS, DDS OF LOUISIANA, A PROFESSIONAL DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6219	LA
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1912251315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANE TEWIS, DDS OF LOUISIANA, A PROFESSIONAL DENTAL LLC

Provider Business Mailing Address
First Line	:	9445 STEVENS RD STE 120
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7573
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9445 STEVENS RD
Second Line	:	STE 120
City	:	SHREVEPORT
State	:	LA
Zip	:	71106
Country	:	US
Telephone Number	:	918-473-8113
Fax Number	:

Authorized Official
Title or Position	:	ENROLLMENT MANAGER
Name	:	HALEY WOOSTER
Credential	:
Telephone Number	:	984-251-8846

Provider Enumeration Date	:	11/07/2012
Last Update Date	:	04/13/2026

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