Provider Demographics
NPI:1356821441
Name:SHANNA G. BURRESS, DMD, PSC
Entity Type:Organization
Organization Name:SHANNA G. BURRESS, DMD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURRESS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-393-4818
Mailing Address - Street 1:2425 SCOTTSVILLE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-4457
Mailing Address - Country:US
Mailing Address - Phone:270-393-4818
Mailing Address - Fax:
Practice Address - Street 1:2425 SCOTTSVILLE RD STE 120
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4457
Practice Address - Country:US
Practice Address - Phone:270-393-4818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty