Healthcare Provider Details

I. General information

NPI: 1649602152
Provider Name (Legal Business Name): SHANNON KELLY LEE D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3896 N MLK BLVD
NORTH LAS VEGAS NV
89032-6603
US

IV. Provider business mailing address

3896 N MLK BLVD
NORTH LAS VEGAS NV
89032-6603
US

V. Phone/Fax

Practice location:
  • Phone: 702-614-1792
  • Fax: 702-933-0190
Mailing address:
  • Phone: 702-614-1792
  • Fax: 702-933-0190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6446
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: