Basic Information
| Provider Information | |||||||||
| NPI: | 1124031315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINDO | ||||||||
| FirstName: | SHARON | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE, SUITE 290 | ||||||||
| Address2: | KOOL SMILES SUPPORT SERVICES OFFICE/NDRC,LLC | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789045665 | ||||||||
| FaxNumber: | 6782477862 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 E VIRGINIA BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235022473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576444356 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 08/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS035800 | PA | N | Dental Providers | Dentist | 122300000X | 0401413330 | VA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1008411900002 | 05 | PA | MEDICAID |