Provider Demographics
NPI:1154766202
Name:REA, SHANNON LORRAINE (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LORRAINE
Last Name:REA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-2153
Mailing Address - Country:US
Mailing Address - Phone:641-682-8143
Mailing Address - Fax:
Practice Address - Street 1:727 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2153
Practice Address - Country:US
Practice Address - Phone:641-682-8143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08954122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist