Provider Demographics
NPI:1588203392
Name:WAILES, SHANNON HARRIS (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:HARRIS
Last Name:WAILES
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 1:605 ESTHER WAY
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5821
Mailing Address - Country:US
Mailing Address - Phone:760-716-5280
Mailing Address - Fax:
Practice Address - Street 1:605 ESTHER WAY
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5821
Practice Address - Country:US
Practice Address - Phone:760-716-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS1100121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program