Individual
DR. SHANE L ELLSWORTH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
704 NE EVANS ST, MCMINNVILLE, OR 97128-3926
(503) 472-1404
Mailing address
704 NE EVANS ST, MCMINNVILLE, OR 97128-3926
(503) 472-1402
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D9517
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004011136
—
CT
Enumeration date
07/19/2007
Last updated
01/06/2011
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