Provider Demographics
NPI:1487180675
Name:DALTON, SHANNEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNEN
Middle Name:
Last Name:DALTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 OAKWOOD HILLS PKWY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3902 OAKWOOD HILLS PKWY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7780
Practice Address - Country:US
Practice Address - Phone:715-835-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001409-15122300000X
GADN0160003122300000X
GADN0160031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist