1427013622 NPI number — SHANNON DENISE PRESLEY-DICKENS DDS

Table of content: SHANNON DENISE PRESLEY-DICKENS DDS (NPI 1427013622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427013622 NPI number — SHANNON DENISE PRESLEY-DICKENS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRESLEY-DICKENS
Provider First Name:
SHANNON
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427013622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 SOUTH WEST STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-753-3797
Provider Business Mailing Address Fax Number:
607-753-6677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 CENTRAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORAVIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13118-3427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-344-0052
Provider Business Practice Location Address Fax Number:
607-344-0056
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  058429 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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