MEDICARE: DR. SHANNON JURESICH

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	27054	FL

General Provider Information

NPI Number	:	1174262976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON JURESICH

Provider Business Mailing Address
First Line	:	301 SW 1ST AVE APT 1916
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-4372
Country	:	US
Telephone Number	:	631-702-3283
Fax Number	:

Provider Business Practice Location Address
First Line	:	4604 N UNIVERSITY DR
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-4628
Country	:	US
Telephone Number	:	631-702-3283
Fax Number	:

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

Provider Enumeration Date	:	05/31/2022
Last Update Date	:	06/14/2022

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