MEDICARE: SHANNON HAVEL 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	019036257	IL

General Provider Information

NPI Number	:	1497646772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON HAVEL DDS

Provider Business Mailing Address
First Line	:	198 W CENTRAL ST
Second Line	:
City	:	RAYMOND
State	:	IA
Zip	:	50667-7713
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2015 W GLEN AVE STE 230
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-4691
Country	:	US
Telephone Number	:	309-673-4616
Fax Number	:

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

Provider Enumeration Date	:	07/14/2025
Last Update Date	:	07/14/2025

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