Provider Demographics
NPI:1417338989
Name:WHEELER, SHANNON SMITH (DMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SMITH
Last Name:WHEELER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-772-8160
Practice Address - Fax:502-772-8108
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9585122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist