Healthcare Provider Details

I. General information

NPI: 1790917227
Provider Name (Legal Business Name): SHANNON GIRARD RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 OLD NECK RD
SCARBOROUGH ME
04074-9401
US

IV. Provider business mailing address

74 ATLANTIC ST APT 1A
PORTLAND ME
04101-5400
US

V. Phone/Fax

Practice location:
  • Phone: 207-513-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3562
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: