Provider Demographics
NPI:1588729172
Name:BREWER, SHANNON RENEE (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:RENEE
Last Name:BREWER
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 1:525 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-3804
Mailing Address - Country:US
Mailing Address - Phone:775-883-4247
Mailing Address - Fax:
Practice Address - Street 1:525 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-3804
Practice Address - Country:US
Practice Address - Phone:775-883-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK56401223G0001X
NV65651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200012920AMedicaid