Provider Demographics
NPI:1215605431
Name:VASQUEZ, SHANA MARIE (LDH, OMT)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:MARIE
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:LDH, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 SWEETBAY PKWY
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:GA
Mailing Address - Zip Code:31811-7624
Mailing Address - Country:US
Mailing Address - Phone:706-801-6227
Mailing Address - Fax:
Practice Address - Street 1:856 SWEETBAY PKWY
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:GA
Practice Address - Zip Code:31811-7624
Practice Address - Country:US
Practice Address - Phone:706-801-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13004579A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist