=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700559382
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON KLINGFORTH RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2021
-----------------------------------------------------
Last Update Date | 07/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 941 MICHIGAN AVE
-----------------------------------------------------
City | STEVENS POINT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-341-4386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2801 HOOVER ROAD PO BOX 828
-----------------------------------------------------
City | STEVENS POINT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 1002597-16
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------