Provider Demographics
NPI:1760563431
Name:SMITH, SHANNON LEIGH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEIGH
Last Name:SMITH
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 1:1106 MYRTLEWOOD CIR E
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-6710
Mailing Address - Country:US
Mailing Address - Phone:561-630-3650
Mailing Address - Fax:
Practice Address - Street 1:860 US HIGHWAY 1
Practice Address - Street 2:101
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-3879
Practice Address - Country:US
Practice Address - Phone:561-624-2047
Practice Address - Fax:561-624-5290
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN160731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice