Provider Demographics
NPI:1477705630
Name:BENJAMIN, SHANNON TRENAY (RDH)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:TRENAY
Last Name:BENJAMIN
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 1:4147 CALDERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-7623
Mailing Address - Country:US
Mailing Address - Phone:318-456-6775
Mailing Address - Fax:
Practice Address - Street 1:1067 TWINING DR
Practice Address - Street 2:
Practice Address - City:BARKSDALE AFB
Practice Address - State:LA
Practice Address - Zip Code:71110-2486
Practice Address - Country:US
Practice Address - Phone:318-456-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4022124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist