Provider Demographics
NPI:1396842779
Name:WIDMIER, SHANNON (DD S PA)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:WIDMIER
Suffix:
Gender:M
Credentials:DD S PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX B
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-0010
Mailing Address - Country:US
Mailing Address - Phone:208-423-6444
Mailing Address - Fax:208-423-6903
Practice Address - Street 1:702 CENTER STREET WEST
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341
Practice Address - Country:US
Practice Address - Phone:208-423-6444
Practice Address - Fax:208-423-6903
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD33421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice