Provider Demographics
NPI:1447263413
Name:CRAIG, SHANNON (DDS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CRAIG
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 1:517 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4640
Mailing Address - Country:US
Mailing Address - Phone:580-225-8611
Mailing Address - Fax:580-225-4971
Practice Address - Street 1:517 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4640
Practice Address - Country:US
Practice Address - Phone:580-225-8611
Practice Address - Fax:580-225-4971
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK51981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice