Healthcare Provider Details

I. General information

NPI: 1639080088
Provider Name (Legal Business Name): SHANNON WILSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 MAIN ST STE C
BROOMFIELD CO
80020-1976
US

IV. Provider business mailing address

3909 W 99TH PL
WESTMINSTER CO
80031-2645
US

V. Phone/Fax

Practice location:
  • Phone: 303-469-3600
  • Fax:
Mailing address:
  • Phone: 307-690-8725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.000906327
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: