Provider Demographics
NPI:1497814388
Name:DOERGE NASCENE, SHANNON MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:DOERGE NASCENE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:DOERGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4345 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3138
Mailing Address - Country:US
Mailing Address - Phone:612-822-1656
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:#390
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-926-3534
Practice Address - Fax:952-926-7085
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice