Provider Demographics
NPI:1811999618
Name:SHANBOUR, GREGORY S (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:SHANBOUR
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 S WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9476
Mailing Address - Country:US
Mailing Address - Phone:405-634-2239
Mailing Address - Fax:405-634-3598
Practice Address - Street 1:8117 S WALKER AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9476
Practice Address - Country:US
Practice Address - Phone:405-634-2239
Practice Address - Fax:405-634-3598
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45851223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4585OtherSTATE DENTAL LICENSE