MEDICARE: MRS. SHANNON MARIE BURDICK 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	4840	CT

General Provider Information

NPI Number	:	1245489152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON MARIE BURDICK RDH

Provider Business Mailing Address
First Line	:	2825 SW EAST LOUISE CIRCLE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953
Country	:	US
Telephone Number	:	772-871-6585
Fax Number	:	561-422-8595

Provider Business Practice Location Address
First Line	:	2825 SW EAST LOUISE CIR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-4273
Country	:	US
Telephone Number	:	772-871-6585
Fax Number	:	561-422-8595

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

Provider Enumeration Date	:	09/16/2008
Last Update Date	:	09/16/2008

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