Healthcare Provider Details

I. General information

NPI: 1750443545
Provider Name (Legal Business Name): SHANEE EDMONDS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 EUCLID AVE
CLEVELAND OH
44103-5059
US

IV. Provider business mailing address

3802 SHANNON RD
CLEVELAND HTS OH
44118-1933
US

V. Phone/Fax

Practice location:
  • Phone: 216-229-7440
  • Fax:
Mailing address:
  • Phone: 615-522-7695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30-023115
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8430
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: