Basic Information
| Provider Information | |||||||||
| NPI: | 1043468721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENEDEK | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.D.H. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 430 MORGAN DR | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140921013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164256451 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 MORGAN DR | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140921013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164256451 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2008 | ||||||||
| LastUpdateDate: | 09/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 025017 | NY | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 025017 | 01 | NY | NYS LICENSE | OTHER |