Provider Demographics
NPI:1841801099
Name:MILLER, SHANNON KELLY (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KELLY
Last Name:MILLER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129 OQUAWKA IL 61469
Mailing Address - Street 2:111 S. 10TH ST. OQUAWKA IL 61469
Mailing Address - City:OQUAWKA
Mailing Address - State:IL
Mailing Address - Zip Code:61469
Mailing Address - Country:US
Mailing Address - Phone:319-759-6644
Mailing Address - Fax:
Practice Address - Street 1:1204 HWY 164 E
Practice Address - Street 2:
Practice Address - City:OQUAWKA
Practice Address - State:IL
Practice Address - Zip Code:61469
Practice Address - Country:US
Practice Address - Phone:309-867-2770
Practice Address - Fax:309-867-3205
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.011534124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist