Provider Demographics
NPI:1235478587
Name:WOOD, SHANNON ELISA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ELISA
Last Name:WOOD
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 1:517 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542-1004
Mailing Address - Country:US
Mailing Address - Phone:812-683-4100
Mailing Address - Fax:812-683-4110
Practice Address - Street 1:517 E 5TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-1004
Practice Address - Country:US
Practice Address - Phone:812-683-4100
Practice Address - Fax:812-683-4110
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009892A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice