Provider Demographics
NPI:1427369198
Name:PICKETT, SHANNON MARIA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIA
Last Name:PICKETT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 43RD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-2762
Mailing Address - Country:US
Mailing Address - Phone:601-616-8383
Mailing Address - Fax:
Practice Address - Street 1:318 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341-2716
Practice Address - Country:US
Practice Address - Phone:662-726-4344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS382209DH124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist