Basic Information
| Provider Information | |||||||||
| NPI: | 1548911233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BITTLE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | DENTAL HYGIENIST | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 513 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629061697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188334471 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 513 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629061697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188334471 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2022 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | IL | Y | Dental Providers | Dental Hygienist |
No ID Information.