Provider Demographics
NPI:1588724041
Name:JACK C SHANNON DDS PC
Entity type:Organization
Organization Name:JACK C SHANNON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:CANADA
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-756-0027
Mailing Address - Street 1:8065 CLUB PARKWAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-5967
Mailing Address - Country:US
Mailing Address - Phone:901-756-0027
Mailing Address - Fax:901-756-9715
Practice Address - Street 1:8065 CLUB PARKWAY
Practice Address - Street 2:SUITE 2
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-5967
Practice Address - Country:US
Practice Address - Phone:901-756-0027
Practice Address - Fax:901-756-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS2485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty