Healthcare Provider Details

I. General information

NPI: 1083642722
Provider Name (Legal Business Name): SHANE DANIEL VANIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N LIBERTY ST STE 304
BOISE ID
83704-8729
US

IV. Provider business mailing address

304 SUN BURST WAY
BOISE ID
83709-0661
US

V. Phone/Fax

Practice location:
  • Phone: 208-407-0079
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3895
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: