Healthcare Provider Details

I. General information

NPI: 1427013622
Provider Name (Legal Business Name): SHANNON DENISE PRESLEY-DICKENS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 CENTRAL ST
MORAVIA NY
13118-3427
US

IV. Provider business mailing address

85 SOUTH WEST STREET
HOMER NY
13077
US

V. Phone/Fax

Practice location:
  • Phone: 607-344-0052
  • Fax: 607-344-0056
Mailing address:
  • Phone: 607-753-3797
  • Fax: 607-753-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number058429
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: