Healthcare Provider Details

I. General information

NPI: 1477637007
Provider Name (Legal Business Name): SHANA LYNNE REIDY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761ST STREET TANK BATALLION BLDG 330
FT HOOD TX
76554
US

IV. Provider business mailing address

116 JESSE JAMES DR
NOLANVILLE TX
76559-2503
US

V. Phone/Fax

Practice location:
  • Phone: 254-285-2014
  • Fax:
Mailing address:
  • Phone: 206-931-8041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: