Provider Demographics
NPI:1477637007
Name:REIDY, SHANA LYNNE (DDS)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:LYNNE
Last Name:REIDY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 JESSE JAMES DR
Mailing Address - Street 2:
Mailing Address - City:NOLANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76559-2503
Mailing Address - Country:US
Mailing Address - Phone:206-931-8041
Mailing Address - Fax:
Practice Address - Street 1:761ST STREET TANK BATALLION
Practice Address - Street 2:BLDG 330
Practice Address - City:FT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76554
Practice Address - Country:US
Practice Address - Phone:254-285-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA229851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice