MEDICARE: SHANA LYNNE REIDY DDS

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	1223G0001X	General Practice Dentistry	22985	CA

General Provider Information

NPI Number	:	1477637007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA LYNNE REIDY DDS

Provider Business Mailing Address
First Line	:	116 JESSE JAMES DR
Second Line	:
City	:	NOLANVILLE
State	:	TX
Zip	:	76559-2503
Country	:	US
Telephone Number	:	206-931-8041
Fax Number	:

Provider Business Practice Location Address
First Line	:	761ST STREET TANK BATALLION
Second Line	:	BLDG 330
City	:	FT HOOD
State	:	TX
Zip	:	76554
Country	:	US
Telephone Number	:	254-285-2014
Fax Number	:

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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