Healthcare Provider Details

I. General information

NPI: 1174577811
Provider Name (Legal Business Name): JEREMY SHANE LANSFORD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 VINE STREET
PASO ROBLES CA
93446
US

IV. Provider business mailing address

1134 VINE STREET
PASO ROBLES CA
93446
US

V. Phone/Fax

Practice location:
  • Phone: 805-238-1441
  • Fax:
Mailing address:
  • Phone: 805-238-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59023
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: