Provider Demographics
NPI:1134504749
Name:NAKAMINE, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NAKAMINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 DENTON HWY
Mailing Address - Street 2:SUITE #100
Mailing Address - City:HALTOM CITY
Mailing Address - State:TX
Mailing Address - Zip Code:76117-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3101 DENTON HWY
Practice Address - Street 2:SUITE #100
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-3706
Practice Address - Country:US
Practice Address - Phone:817-831-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31206122300000X
CA64604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist