Provider Demographics
NPI:1144389453
Name:WILLIAMS, SHANNON J (DDS)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:J
Last Name:WILLIAMS
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 1:909 GREYSTONE ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1206
Mailing Address - Country:US
Mailing Address - Phone:405-414-8108
Mailing Address - Fax:
Practice Address - Street 1:510 S DUCK ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4051
Practice Address - Country:US
Practice Address - Phone:405-377-7300
Practice Address - Fax:405-377-7301
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200056630AMedicaid