Basic Information
| Provider Information | |||||||||
| NPI: | 1194024869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMPLE | ||||||||
| FirstName: | SHEMIKA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389306509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623746450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 344 UNIVERSITY BLVD W | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209011948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024838196 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0401414041 | VA | N | Dental Providers | Dentist | 122300000X | 17477 | MD | Y | Dental Providers | Dentist |
No ID Information.