Basic Information
| Provider Information | |||||||||
| NPI: | 1144389453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 GREYSTONE ST | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740741206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054148108 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 510 S DUCK ST | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053777300 | ||||||||
| FaxNumber: | 4053777301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 10/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5208 | OK | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 200056630A | 05 | OK | MEDICAID |