Healthcare Provider Details

I. General information

NPI: 1023175528
Provider Name (Legal Business Name): SHABNAM PENRY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10950 SAN JOSE BLVD SUITE 64
JACKSONVILLE FL
32223-6688
US

IV. Provider business mailing address

10950 SAN JOSE BLVD SUITE 64
JACKSONVILLE FL
32223-6688
US

V. Phone/Fax

Practice location:
  • Phone: 904-260-4244
  • Fax: 904-292-0866
Mailing address:
  • Phone: 904-260-4244
  • Fax: 904-292-0866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30022434
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: