Provider Demographics
NPI:1073846408
Name:SKIBA, SHANNON C (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:C
Last Name:SKIBA
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 1:157 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3597
Mailing Address - Country:US
Mailing Address - Phone:770-478-1001
Mailing Address - Fax:770-478-1001
Practice Address - Street 1:157 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3597
Practice Address - Country:US
Practice Address - Phone:770-478-1001
Practice Address - Fax:770-478-1001
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.023118122300000X
GADN0152531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist