MEDICARE: DR. SHANNON VICKERY 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	5165	AL
2	1223G0001X	General Practice Dentistry	5165	AL
3	1223G0001X	General Practice Dentistry	9092	KY

General Provider Information

NPI Number	:	1427162544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON VICKERY DMD

Provider Business Mailing Address
First Line	:	9706 TAYLORSVILLE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40299-2753
Country	:	US
Telephone Number	:	502-438-5387
Fax Number	:

Provider Business Practice Location Address
First Line	:	9706 TAYLORSVILLE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40299-2753
Country	:	US
Telephone Number	:	502-267-0546
Fax Number	:	502-267-7306

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

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	03/22/2016

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