MEDICARE: SHANEL W COOK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	30.026431	OH
2	122300000X	Dentist	34837	TX
3	1223G0001X	General Practice Dentistry	34837	TX

General Provider Information

NPI Number	:	1861965998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANEL W COOK

Provider Business Mailing Address
First Line	:	4633 175TH PL
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-4530
Country	:	US
Telephone Number	:	312-312-3923
Fax Number	:

Provider Business Practice Location Address
First Line	:	4633 175TH PL
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-4530
Country	:	US
Telephone Number	:	312-312-3923
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2019
Last Update Date	:	06/05/2025

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Directions to “ SHANEL W COOK ” Practice Location

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