Provider Demographics
NPI:1962741678
Name:SHONGO, RENEE G (DMD, PA)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:G
Last Name:SHONGO
Suffix:
Gender:F
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3655
Mailing Address - Country:US
Mailing Address - Phone:803-794-0905
Mailing Address - Fax:803-794-5472
Practice Address - Street 1:163 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3655
Practice Address - Country:US
Practice Address - Phone:803-794-0905
Practice Address - Fax:803-794-5472
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2575122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist