Provider Demographics
NPI:1144312836
Name:SHANE ISTRE DENTAL ASSOCIATES
Entity type:Organization
Organization Name:SHANE ISTRE DENTAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHAYNE
Authorized Official - Last Name:ISTRE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-535-8911
Mailing Address - Street 1:1144 AIRPORT BLVD
Mailing Address - Street 2:#240
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702
Mailing Address - Country:US
Mailing Address - Phone:512-929-7888
Mailing Address - Fax:512-929-8091
Practice Address - Street 1:1144 AIRPORT BLVD
Practice Address - Street 2:#240
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702
Practice Address - Country:US
Practice Address - Phone:512-929-7888
Practice Address - Fax:512-929-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091333701Medicaid
TXG60109-3OtherTEXAS CHIP