Provider Demographics
NPI:1124031315
Name:LINDO, SHARON (DMD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:LINDO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE, SUITE 290
Mailing Address - Street 2:KOOL SMILES SUPPORT SERVICES OFFICE/NDRC,LLC
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067
Mailing Address - Country:US
Mailing Address - Phone:678-904-5665
Mailing Address - Fax:678-247-7862
Practice Address - Street 1:5900 E VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2473
Practice Address - Country:US
Practice Address - Phone:757-644-4356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035800122300000X
VA0401413330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1008411900002Medicaid