Provider Demographics
NPI:1477681146
Name:WILSON, SHANNON BROCK (DMD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:BROCK
Last Name:WILSON
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 1:19 SHIRMADON DR
Mailing Address - Street 2:
Mailing Address - City:HONEA PATH
Mailing Address - State:SC
Mailing Address - Zip Code:29654-1533
Mailing Address - Country:US
Mailing Address - Phone:864-369-2966
Mailing Address - Fax:864-369-0666
Practice Address - Street 1:19 SHIRMADON DR
Practice Address - Street 2:
Practice Address - City:HONEA PATH
Practice Address - State:SC
Practice Address - Zip Code:29654-1533
Practice Address - Country:US
Practice Address - Phone:864-369-2966
Practice Address - Fax:864-369-0666
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3886122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist