MEDICARE: SHANE MATTHEW WELLINGTON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	30021714	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295794667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE MATTHEW WELLINGTON DMD

Provider Business Mailing Address
First Line	:	1609 PENNSYLVANIA AVE
Second Line	:
City	:	EAST LIVERPOOL
State	:	OH
Zip	:	43920
Country	:	US
Telephone Number	:	330-385-1352
Fax Number	:	330-385-7409

Provider Business Practice Location Address
First Line	:	1609 PENNSYLVANIA AVE
Second Line	:
City	:	EAST LIVERPOOL
State	:	OH
Zip	:	43920
Country	:	US
Telephone Number	:	330-385-1352
Fax Number	:	330-385-7407

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	09/28/2012

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