Provider Demographics
NPI:1770994345
Name:ETIENNE, SHANGO SHEMBO (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANGO
Middle Name:SHEMBO
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 MALLARD CREEK RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-5206
Mailing Address - Country:US
Mailing Address - Phone:704-503-0202
Mailing Address - Fax:
Practice Address - Street 1:10400 MALLARD CREEK RD STE 103
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5206
Practice Address - Country:US
Practice Address - Phone:704-503-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice