Provider Demographics
NPI:1780378000
Name:REAGAN, SHANIN RAE (DMD)
Entity type:Individual
Prefix:DR
First Name:SHANIN
Middle Name:RAE
Last Name:REAGAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 BUNCOMBE ST APT 215
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-1938
Mailing Address - Country:US
Mailing Address - Phone:630-207-4781
Mailing Address - Fax:
Practice Address - Street 1:105 STATE PARK RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-2914
Practice Address - Country:US
Practice Address - Phone:864-271-1156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice