Provider Demographics
NPI:1386202273
Name:SHALL, LINDSEY
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:SHALL
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 1:1200 NETWORK CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4602
Mailing Address - Country:US
Mailing Address - Phone:217-540-8386
Mailing Address - Fax:
Practice Address - Street 1:1200 NETWORK CENTRE DR
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-4602
Practice Address - Country:US
Practice Address - Phone:217-540-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00204017122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist