Provider Demographics
NPI:1811179559
Name:JORGENSEN, SHONNA MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:SHONNA
Middle Name:MARIE
Last Name:JORGENSEN
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 1:540 VILLAGE WALK LN
Mailing Address - Street 2:SUITE E
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038-9554
Mailing Address - Country:US
Mailing Address - Phone:920-699-2554
Mailing Address - Fax:920-699-3059
Practice Address - Street 1:540 VILLAGE WALK LN
Practice Address - Street 2:SUITE E
Practice Address - City:JOHNSON CREEK
Practice Address - State:WI
Practice Address - Zip Code:53038-9554
Practice Address - Country:US
Practice Address - Phone:920-699-2554
Practice Address - Fax:920-699-3059
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6203-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice