Provider Demographics
NPI:1316249980
Name:BULL, SHANNON R (DMD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:BULL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 FLOYD CURL DRIVE UT HEALTH SCIENCE CENTER AT SAN A
Mailing Address - Street 2:MSC 7914, DEPT OF COMPREHENSIVE DENTISTRY
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3900
Mailing Address - Country:US
Mailing Address - Phone:210-567-3456
Mailing Address - Fax:210-567-3443
Practice Address - Street 1:7703 FLOYD CURL DRIVE UT HEALTH SCIENCE CENTER AT SAN A
Practice Address - Street 2:MSC 7903, ADVANCED GENERAL DENTISTRY CLINIC
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3900
Practice Address - Country:US
Practice Address - Phone:210-567-3456
Practice Address - Fax:210-567-3443
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXUTSA930-X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice