Provider Demographics
NPI:1427162544
Name:VICKERY, SHANNON (DMD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:VICKERY
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 1:9706 TAYLORSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2753
Mailing Address - Country:US
Mailing Address - Phone:502-438-5387
Mailing Address - Fax:
Practice Address - Street 1:9706 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-2753
Practice Address - Country:US
Practice Address - Phone:502-267-0546
Practice Address - Fax:502-267-7306
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5165122300000X, 1223G0001X
KY90921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist