Provider Demographics
NPI:1841823143
Name:BLAIR, SHANNON KELLY (DDS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KELLY
Last Name:BLAIR
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:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:575-587-2205
Mailing Address - Fax:
Practice Address - Street 1:15136 NM-75
Practice Address - Street 2:
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553
Practice Address - Country:US
Practice Address - Phone:575-587-2205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1067831223G0001X
NMDD220131223G0001X
NMTD-00-126390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice