Provider Demographics
NPI:1316452279
Name:WILSON, SHAUNA ELAINE (RDH)
Entity type:Individual
Prefix:MRS
First Name:SHAUNA
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:SHAUNA
Other - Middle Name:ELAINE
Other - Last Name:RAMEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1251 LANCASTER DR NE, SUITE B
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-587-9633
Mailing Address - Fax:
Practice Address - Street 1:1251 LANCASTER DR NE, B
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-587-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist