Provider Demographics
NPI:1649602152
Name:LEE, SHANNON KELLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KELLY
Last Name:LEE
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 1:3896 N MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-6603
Mailing Address - Country:US
Mailing Address - Phone:702-614-1792
Mailing Address - Fax:702-933-0190
Practice Address - Street 1:3896 N MLK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-6603
Practice Address - Country:US
Practice Address - Phone:702-614-1792
Practice Address - Fax:702-933-0190
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6446122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist