=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386221976
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON RENEE VUJINOVIC CRDH, BASDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2021
-----------------------------------------------------
Last Update Date | 03/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12123 LITTLE RD
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667-2924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-379-9250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10881 STRADA LN APT 203
-----------------------------------------------------
City | TRINITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34655-5093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-656-0943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH24727
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------