Provider Demographics
NPI:1043878358
Name:WALKER, SHANNAN JESSE (DDS)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:JESSE
Last Name:WALKER
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 1:625 SCRUB OAK RD
Mailing Address - Street 2:
Mailing Address - City:MANITOU SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80829-2543
Mailing Address - Country:US
Mailing Address - Phone:607-372-3186
Mailing Address - Fax:
Practice Address - Street 1:2410 SAMPSON ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-2942
Practice Address - Country:US
Practice Address - Phone:847-688-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00204008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist