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General NPI Number Information
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NPI Number | 1902014863
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Entity Type | Individual
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Provider Name | SHANNONJ LEE FENTON RDA
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Gender | Female
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 3155 W INDIAN SCHOOL RD
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City | PHOENIX
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State | AZ
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Zip | 85017-4035
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Country | US
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Telephone | 602-212-9533
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Fax |
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Provider Business Mailing Address
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Address Line | 3530 E MORELAND ST APT 3
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City | PHOENIX
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State | AZ
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Zip | 85008-5247
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Country | US
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Telephone | 480-430-1172
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 31911
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License Number State | CA
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