Provider Demographics
NPI:1861531444
Name:KAISER, SHANNON JANE (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:JANE
Last Name:KAISER
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 1:4019 WILKENS AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229
Mailing Address - Country:US
Mailing Address - Phone:410-644-2200
Mailing Address - Fax:410-664-5064
Practice Address - Street 1:4019 WILKENS AVENUE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:410-644-2200
Practice Address - Fax:410-664-5064
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD114661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice