Healthcare Provider Details

I. General information

NPI: 1750724613
Provider Name (Legal Business Name): SHANE T COPE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 STATE ROAD 26 E SUITE 100
LAFAYETTE IN
47905-4608
US

IV. Provider business mailing address

4921 STATE ROAD 26 EAST SUITE 100
LAFAYETTE IN
47905-4616
US

V. Phone/Fax

Practice location:
  • Phone: 765-807-0592
  • Fax: 765-269-7696
Mailing address:
  • Phone: 765-807-0592
  • Fax: 765-269-7696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number12011052A
License Number StateIN

VIII. Authorized Official

Name: DR. SHANE T COPE
Title or Position: OWNER
Credential: DDS
Phone: 765-807-0592