Provider Demographics
NPI:1366013930
Name:WALL, SHANNON DANIELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:DANIELLE
Last Name:WALL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8430 PERSHALL RD
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-3075
Mailing Address - Country:US
Mailing Address - Phone:314-521-5678
Mailing Address - Fax:314-521-0283
Practice Address - Street 1:8430 PERSHALL RD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-3075
Practice Address - Country:US
Practice Address - Phone:314-521-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210211591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice