Provider Demographics
NPI:1407029101
Name:SCHVANEVELDT, SHANE LEE (DDS, MCLD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:LEE
Last Name:SCHVANEVELDT
Suffix:
Gender:M
Credentials:DDS, MCLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 DAWSON DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3195
Mailing Address - Country:US
Mailing Address - Phone:208-734-4600
Mailing Address - Fax:
Practice Address - Street 1:2085 DAWSON DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3195
Practice Address - Country:US
Practice Address - Phone:208-734-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3515-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806662500Medicaid