Provider Demographics
NPI:1588344824
Name:ALLEN, SHANNON (DMD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 PHOENIX CT
Mailing Address - Street 2:
Mailing Address - City:SCOTT AIR FORCE BASE
Mailing Address - State:IL
Mailing Address - Zip Code:62225-6311
Mailing Address - Country:US
Mailing Address - Phone:847-345-9556
Mailing Address - Fax:
Practice Address - Street 1:21 GLEN ED PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3333
Practice Address - Country:US
Practice Address - Phone:618-656-0608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7789122300000X
IL019.035371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist