=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205361862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHANE DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2017
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 WALNUT ST UNIT A
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-386-2133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 WALNUT ST UNIT A
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-386-2133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KELVIN SHANE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 715-386-2133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 100148715
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------