Provider Demographics
NPI:1205387644
Name:DENT, SHANELL
Entity Type:Individual
Prefix:
First Name:SHANELL
Middle Name:
Last Name:DENT
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 1:1928 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2031
Mailing Address - Country:US
Mailing Address - Phone:580-716-8487
Mailing Address - Fax:
Practice Address - Street 1:620 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-5123
Practice Address - Country:US
Practice Address - Phone:580-762-1462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist