# SHANE DAVIDSON DDS PC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** SHANE DAVIDSON DDS PC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1033651427
- **Legal business name:** SHANE DAVIDSON DDS PC
- **Authorized official:** SHANE DAVIDSON DDS (OWNER)
- **Authorized official phone:** (248) 977-3006

## Contact information

- **Practice address:** 5574 COOLEY LAKE RD, WATERFORD, MI 48327-3015
- **Practice address phone:** (248) 977-3006
- **Mailing address:** 5574 COOLEY LAKE RD, WATERFORD, MI 48327-3015
- **Mailing address phone:** (248) 977-3006

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 2901020222 | MI | Yes |

## Other

- **Enumeration date:** 11/16/2016
- **Last updated:** 11/16/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 2901020222 | — | MI |