Provider Demographics
NPI:1821349903
Name:WENAAS, SHANNON MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:WENAAS
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 1:3376 S JOSHUA TREE LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7854
Mailing Address - Country:US
Mailing Address - Phone:602-363-9338
Mailing Address - Fax:
Practice Address - Street 1:4803 E RAY RD STE P002C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044
Practice Address - Country:US
Practice Address - Phone:480-755-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2018-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.8153 GD1223G0001X
AZD0086901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice