Provider Demographics
NPI:1588979009
Name:CITRON, SHANE T (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:T
Last Name:CITRON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5090 E HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7637
Mailing Address - Country:US
Mailing Address - Phone:810-445-9970
Mailing Address - Fax:810-445-9971
Practice Address - Street 1:5090 E HILL RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7637
Practice Address - Country:US
Practice Address - Phone:810-445-9970
Practice Address - Fax:810-445-9971
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03796204E00000X
MI2901017389204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery