Provider Demographics
NPI:1205914595
Name:GREEN, SHANNON DALE (DMD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:DALE
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 GRAHAM ST SW
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-5238
Mailing Address - Country:US
Mailing Address - Phone:256-734-1656
Mailing Address - Fax:256-734-1659
Practice Address - Street 1:322 GRAHAM ST SW
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-5238
Practice Address - Country:US
Practice Address - Phone:256-734-1656
Practice Address - Fax:256-734-1659
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL47851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice