Provider Demographics
NPI:1356527949
Name:SC SHINE PLLC
Entity type:Organization
Organization Name:SC SHINE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:COKE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:210-495-2000
Mailing Address - Street 1:2211 NW MILITARY HWY
Mailing Address - Street 2:SUITE 212
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1859
Mailing Address - Country:US
Mailing Address - Phone:210-495-2000
Mailing Address - Fax:210-495-2001
Practice Address - Street 1:10103 W LOOP 1604 N
Practice Address - Street 2:STE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-9715
Practice Address - Country:US
Practice Address - Phone:210-495-2000
Practice Address - Fax:210-495-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty