Provider Demographics
NPI:1538397179
Name:SENA, SHANNON MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MICHAEL
Last Name:SENA
Suffix:
Gender:M
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:PO BOX 150575
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89315-0575
Mailing Address - Country:US
Mailing Address - Phone:775-354-6627
Mailing Address - Fax:
Practice Address - Street 1:1500 AVENUE F
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-3506
Practice Address - Country:US
Practice Address - Phone:775-289-3375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5934122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025205100Medicaid