Provider Demographics
NPI:1003549122
Name:BLACK, SHANON (DDS)
Entity Type:Individual
Prefix:
First Name:SHANON
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 S DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4427
Mailing Address - Country:US
Mailing Address - Phone:785-766-8786
Mailing Address - Fax:
Practice Address - Street 1:316 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-5548
Practice Address - Country:US
Practice Address - Phone:405-372-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice