Healthcare Provider Details

I. General information

NPI: 1548499205
Provider Name (Legal Business Name): JILL M SHONKA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 11/10/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 MAIN ST UNIT C
WINDSOR CO
80550-5918
US

IV. Provider business mailing address

1576 MAIN STREET
WINDSOR CO
80550-5918
US

V. Phone/Fax

Practice location:
  • Phone: 970-674-3247
  • Fax:
Mailing address:
  • Phone: 970-674-3247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10346
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: