Provider Demographics
NPI:1780427096
Name:BOONE, SHANDON DEMETRIUS (DDS)
Entity type:Individual
Prefix:
First Name:SHANDON
Middle Name:DEMETRIUS
Last Name:BOONE
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 1:8961 METCALF AVE APT 543
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-1587
Mailing Address - Country:US
Mailing Address - Phone:314-277-4146
Mailing Address - Fax:
Practice Address - Street 1:15834 SHAWNEE MISSION PKWY
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66217-9326
Practice Address - Country:US
Practice Address - Phone:913-631-0866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS621471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice