Provider Demographics
NPI:1083872915
Name:BRIDGERS, SHANNITTA LATREASE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANNITTA
Middle Name:LATREASE
Last Name:BRIDGERS
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 1:1367 WALTER REED RD STE 103
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4445
Mailing Address - Country:US
Mailing Address - Phone:910-485-8749
Mailing Address - Fax:910-485-8398
Practice Address - Street 1:1367 WALTER REED RD
Practice Address - Street 2:SUITE 103
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304
Practice Address - Country:US
Practice Address - Phone:910-485-8749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC85681223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911135Medicaid