Healthcare Provider Details

I. General information

NPI: 1841823143
Provider Name (Legal Business Name): SHANNON KELLY BLAIR DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2020
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC11 6093 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-4516
US

IV. Provider business mailing address

MSC11 6093 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4031
  • Fax: 505-925-4031
Mailing address:
  • Phone: 505-925-4031
  • Fax: 505-925-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTD-00-126
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: