Healthcare Provider Details

I. General information

NPI: 1245713601
Provider Name (Legal Business Name): SHANNON K CARTER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2837 STABLE DR STE A
KIMBALL MI
48074-1441
US

IV. Provider business mailing address

2837 STABLE DR STE A
KIMBALL MI
48074-1441
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-3301
  • Fax: 855-747-1702
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902012674
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: