MEDICARE: DR. SHANE TEWIS DDS

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	5533	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962498519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANE TEWIS DDS

Provider Business Mailing Address
First Line	:	530 PLAZA CT
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-7915
Country	:	US
Telephone Number	:	918-245-8333
Fax Number	:	918-245-8338

Provider Business Practice Location Address
First Line	:	530 PLAZA CT
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-7915
Country	:	US
Telephone Number	:	918-245-8333
Fax Number	:	918-245-8338

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	08/08/2012

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Directions to “ DR. SHANE TEWIS DDS” Practice Location

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