Healthcare Provider Details

I. General information

NPI: 1700779931
Provider Name (Legal Business Name): SHANDA PFIZENMAIER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 05/29/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 BEEMAN PL
FORT RILEY KS
66442-7009
US

IV. Provider business mailing address

701 HIGHLAND RIDGE DR APT 4A
MANHATTAN KS
66503-0333
US

V. Phone/Fax

Practice location:
  • Phone: 785-239-7226
  • Fax:
Mailing address:
  • Phone: 785-320-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number12898
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: