Provider Demographics
NPI:1063620706
Name:SHANNON, SHANNON (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:SHANNON
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 1:221 S CATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2313
Mailing Address - Country:US
Mailing Address - Phone:708-579-9044
Mailing Address - Fax:708-579-9044
Practice Address - Street 1:21 N DELAPLAINE RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2022
Practice Address - Country:US
Practice Address - Phone:708-447-2100
Practice Address - Fax:708-447-0654
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist