Basic Information
| Provider Information | |||||||||
| NPI: | 1841823143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | KELLY | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26477 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913502973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612531010 | ||||||||
| FaxNumber: | 5059254030 | ||||||||
| Practice Location | |||||||||
| Address1: | 26477 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913502973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612531010 | ||||||||
| FaxNumber: | 5059254031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2020 | ||||||||
| LastUpdateDate: | 03/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DDS106783 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.