Provider Demographics
NPI:1679515357
Name:SHANLEY, MELVIN LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:LEE
Last Name:SHANLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 MOONLIGHT WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1688
Mailing Address - Country:US
Mailing Address - Phone:210-697-7377
Mailing Address - Fax:210-697-7319
Practice Address - Street 1:4315 MOONLIGHT WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1688
Practice Address - Country:US
Practice Address - Phone:210-697-7377
Practice Address - Fax:210-697-7319
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX156681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX008956701Medicaid