Healthcare Provider Details

I. General information

NPI: 1386830503
Provider Name (Legal Business Name): SHANE TRAVIS COPE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 E 10TH ST
INDIANAPOLIS IN
46201-2824
US

IV. Provider business mailing address

4604 E 10TH ST
INDIANAPOLIS IN
46201-2824
US

V. Phone/Fax

Practice location:
  • Phone: 317-353-8505
  • Fax:
Mailing address:
  • Phone: 317-353-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011052A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: