Provider Demographics
NPI:1649724782
Name:ROCHE, SHANE PATRICK (DMD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:PATRICK
Last Name:ROCHE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 SIGNATURE DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-3867
Mailing Address - Country:US
Mailing Address - Phone:330-881-6197
Mailing Address - Fax:
Practice Address - Street 1:1001 COVINGTON ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44510-1617
Practice Address - Country:US
Practice Address - Phone:330-480-1366
Practice Address - Fax:330-480-1366
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program