MEDICARE: DR. JENNIFER SHANNON STACHEL DMD

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	122300000X	Dentist	50053294	NY

General Provider Information

NPI Number	:	1326221094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER SHANNON STACHEL DMD

Provider Business Mailing Address
First Line	:	100 GLEN ST APT 2226
Second Line	:
City	:	GLEN COVE
State	:	NY
Zip	:	11542-2737
Country	:	US
Telephone Number	:	631-612-4840
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 PORTION RD
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4587
Country	:	US
Telephone Number	:	631-588-1199
Fax Number	:

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

Provider Enumeration Date	:	12/17/2007
Last Update Date	:	12/17/2007

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