Provider Demographics
NPI:1902906795
Name:BHARGAVA, SHANNON M (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:M
Last Name:BHARGAVA
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 1:4431 N CHERRY HILL ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-4221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1230 N BROADMOOR AVE
Practice Address - Street 2:STE 300
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3891
Practice Address - Country:US
Practice Address - Phone:316-630-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS601811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice