Provider Demographics
NPI:1164498507
Name:HERRING, SHANA K
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:K
Last Name:HERRING
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 1:143 CANAL ST STE 400
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-6016
Mailing Address - Country:US
Mailing Address - Phone:912-748-2303
Mailing Address - Fax:
Practice Address - Street 1:143 CANAL ST STE 400
Practice Address - Street 2:SUITE #2
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-6016
Practice Address - Country:US
Practice Address - Phone:912-748-2303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-26
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0123281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA623961158AMedicaid
GA9180195OtherDORAL