Provider Demographics
NPI:1902014863
Name:FENTON, SHANNONJ LEE (RDA)
Entity Type:Individual
Prefix:
First Name:SHANNONJ
Middle Name:LEE
Last Name:FENTON
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 E MORELAND ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-5247
Mailing Address - Country:US
Mailing Address - Phone:480-430-1172
Mailing Address - Fax:
Practice Address - Street 1:3155 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4035
Practice Address - Country:US
Practice Address - Phone:602-212-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA319111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ42696Medicare UPIN