Provider Demographics
NPI:1437011764
Name:BRYAN J. SHANAHAN DDS, PC
Entity type:Organization
Organization Name:BRYAN J. SHANAHAN DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-634-9366
Mailing Address - Street 1:322 S MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:322 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3693
Practice Address - Country:US
Practice Address - Phone:928-634-9366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-25
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty