Provider Demographics
NPI:1134696156
Name:WHEELER, SHONNA
Entity type:Individual
Prefix:
First Name:SHONNA
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3380 C ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-3949
Mailing Address - Country:US
Mailing Address - Phone:907-277-1440
Mailing Address - Fax:907-277-1436
Practice Address - Street 1:100 SLOCUM DRIVE
Practice Address - Street 2:
Practice Address - City:KING COVE
Practice Address - State:AK
Practice Address - Zip Code:99612
Practice Address - Country:US
Practice Address - Phone:907-497-2311
Practice Address - Fax:907-497-2310
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK18150DHAT125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist