Provider Demographics
NPI:1255064952
Name:WILSON, SHANNON MURRAY (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MURRAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 N 83RD ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-4208
Mailing Address - Country:US
Mailing Address - Phone:206-920-5430
Mailing Address - Fax:
Practice Address - Street 1:142 N 83RD ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-4208
Practice Address - Country:US
Practice Address - Phone:206-920-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE612879081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice