Provider Demographics
NPI:1023152519
Name:SAMUELS FARMER, SHANNON SUE (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:SUE
Last Name:SAMUELS FARMER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:S
Other - Last Name:SAMUELS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:735 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3043
Mailing Address - Country:US
Mailing Address - Phone:630-262-8218
Mailing Address - Fax:
Practice Address - Street 1:309 HAMILTON ST
Practice Address - Street 2:SUITE C
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2134
Practice Address - Country:US
Practice Address - Phone:630-232-1111
Practice Address - Fax:630-232-1131
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice