MEDICARE: SHANNON ROLF RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	000904276	CO

General Provider Information

NPI Number	:	1023404399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON ROLF RDH

Provider Business Mailing Address
First Line	:	1512 N UNION BLVD
Second Line	:	STE101
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-2884
Country	:	US
Telephone Number	:	719-633-2266
Fax Number	:

Provider Business Practice Location Address
First Line	:	1512 N UNION BLVD
Second Line	:	STE101
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-2884
Country	:	US
Telephone Number	:	719-633-2266
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2015
Last Update Date	:	04/13/2015

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