Provider Demographics
NPI:1063725745
Name:KING, SHAUNTA' SHAWAN (DMD)
Entity type:Individual
Prefix:DR
First Name:SHAUNTA'
Middle Name:SHAWAN
Last Name:KING
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2604
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-2604
Mailing Address - Country:US
Mailing Address - Phone:404-919-5898
Mailing Address - Fax:
Practice Address - Street 1:8500 W 110TH ST STE 450
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-4029
Practice Address - Country:US
Practice Address - Phone:404-919-5898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014131122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA877878469AMedicaid
GA877878469BMedicaid
GADN014131OtherDMD LICENSE