Provider Demographics
NPI:1750724613
Name:SHANE T COPE LLC
Entity type:Organization
Organization Name:SHANE T COPE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:T
Authorized Official - Last Name:COPE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-807-0592
Mailing Address - Street 1:4921 STATE ROAD 26 EAST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4616
Mailing Address - Country:US
Mailing Address - Phone:765-807-0592
Mailing Address - Fax:765-269-7696
Practice Address - Street 1:4921 STATE ROAD 26 E
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4608
Practice Address - Country:US
Practice Address - Phone:765-807-0592
Practice Address - Fax:765-269-7696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011052A261QD0000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200880660Medicaid