Provider Demographics
NPI:1477009793
Name:CAROTHERS, SHAWANDA (RDH)
Entity Type:Individual
Prefix:MS
First Name:SHAWANDA
Middle Name:
Last Name:CAROTHERS
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 1:8321 S HERMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-4630
Mailing Address - Country:US
Mailing Address - Phone:773-386-4222
Mailing Address - Fax:
Practice Address - Street 1:8321 S. HERMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-4630
Practice Address - Country:US
Practice Address - Phone:773-386-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.013060124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist