Dental Board of California
Licensing details for: 61439
Name: DOUGLAS, SHANE MARK
License Type: Dentist
Primary Status: Current - Active
Method of Application: Licensure by WREB
Previous Names: DOUGLAS, SHANE M
Address of Record
3700 ATHERTON RD
ROCKLIN CA 95765
PLACER county
Map
License Relationships
CS to DDS, OMS, or SP
License/Registration Role: Must hold an active Dental License, Oral Maxillofacial Surgery Permit, or Special Permit
Related Party Role: Conscious Sedation Permit
Name: DOUGLAS, SHANE MARK
License/Registration Type: Conscious Sedation Permit
License Number: 949 Primary Status: Cancelled
Address :
3700 ATHERTON ROAD
ROCKLIN CA 95765
PLACER COUNTY
FNP to DDS or OMS
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Fictitious Name Permit
Name: HERITAGE OAK DENTAL, PRACTICE OF SHANE DOUGLAS, DDS PC
License/Registration Type: Fictitious Name Permit
License Number: 10413 Primary Status: Expired
Address :
3700 ATHERTON ROAD
ROCKLIN CA 95765
PLACER COUNTY
FNP to DDS or OMS
License/Registration Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Related Party Role: Fictitious Name Permit
Name: HERITAGE OAK DENTAL PRACTICE OF DOUGLAS & KLOSS DENTAL PARTNERSHIP
License/Registration Type: Fictitious Name Permit
License Number: 16125 Primary Status: Current - Active
Address :
3700 ATHERTON RD
ROCKLIN CA 95765
PLACER COUNTY
MS to DDS or OMS or SP
License/Registration Role: Must hold an active Dental License, Oral Maxillofacial Surgery Permit, or Special Permit
Related Party Role: Moderate Sedation Permit
Name: DOUGLAS, SHANE MARK
License/Registration Type: Moderate Sedation Permit
License Number: 420 Primary Status: Current - Active
Address :
3700 ATHERTON RD.
ROCKLIN CA 95765
PLACER COUNTY
