Provider Demographics
NPI:1124063250
Name:SHANNON, RAYANNE F (DDS)
Entity type:Individual
Prefix:
First Name:RAYANNE
Middle Name:F
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 1:2615 ELK DR
Mailing Address - Street 2:STE 3
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-1200
Mailing Address - Country:US
Mailing Address - Phone:701-852-3421
Mailing Address - Fax:701-838-1842
Practice Address - Street 1:2615 ELK DR
Practice Address - Street 2:STE 3
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-1200
Practice Address - Country:US
Practice Address - Phone:701-852-3421
Practice Address - Fax:701-838-1842
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND18551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1855OtherDENTAL LICENSE
ND41251Medicaid