Provider Demographics
NPI:1962790261
Name:AJ SHANNON DMD PLC
Entity type:Organization
Organization Name:AJ SHANNON DMD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:571-230-8051
Mailing Address - Street 1:301 MAPLE AVE W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4301
Mailing Address - Country:US
Mailing Address - Phone:703-319-8370
Mailing Address - Fax:703-319-8371
Practice Address - Street 1:301 MAPLE AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4301
Practice Address - Country:US
Practice Address - Phone:703-319-8370
Practice Address - Fax:703-319-8371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014117731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982825097Medicaid