Provider Demographics
NPI:1144588559
Name:SHANBOUR, GREGORY FARRIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:FARRIS
Last Name:SHANBOUR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 S WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9476
Mailing Address - Country:US
Mailing Address - Phone:405-634-2239
Mailing Address - Fax:405-634-3598
Practice Address - Street 1:8117 S WALKER AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9476
Practice Address - Country:US
Practice Address - Phone:405-634-2239
Practice Address - Fax:405-634-3598
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK65491223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty