Provider Demographics
NPI:1639529340
Name:WALKER, SHANNON (RDH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:STAMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:MIL PARK AVE BLDG 9119
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-966-9960
Mailing Address - Fax:
Practice Address - Street 1:MIL PARK AVE BLDG 9119
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-966-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3299124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist