Provider Demographics
NPI:1467560185
Name:VANN, SHANNON DUDLEY (DDS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DUDLEY
Last Name:VANN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:REBECCA
Other - Last Name:DUDLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:110 E WALL STREET
Mailing Address - City:RURAL HALL
Mailing Address - State:NC
Mailing Address - Zip Code:27045-0039
Mailing Address - Country:US
Mailing Address - Phone:336-969-6888
Mailing Address - Fax:336-969-5101
Practice Address - Street 1:110 E WALL ST
Practice Address - Street 2:
Practice Address - City:RURAL HALL
Practice Address - State:NC
Practice Address - Zip Code:27045-9312
Practice Address - Country:US
Practice Address - Phone:336-969-6888
Practice Address - Fax:336-969-5101
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901049Medicaid
9021NOtherBLUE CROSS BLUE SHIELD NC