Provider Demographics
NPI:1871200915
Name:GILL, SHANNON (RDH)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GILL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 17TH AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-1738
Mailing Address - Country:US
Mailing Address - Phone:720-526-8876
Mailing Address - Fax:
Practice Address - Street 1:2350 17TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-1738
Practice Address - Country:US
Practice Address - Phone:720-526-8876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905153124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist