Provider Demographics
NPI:1073695326
Name:NORMAN-KOTRE, SHANNON (DDS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NORMAN-KOTRE
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 1:2240 S HURON PKWY
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5151
Mailing Address - Country:US
Mailing Address - Phone:734-677-2156
Mailing Address - Fax:734-677-2638
Practice Address - Street 1:2240 S HURON PKWY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5151
Practice Address - Country:US
Practice Address - Phone:734-677-2156
Practice Address - Fax:734-677-2638
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010176291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1382114OtherCONCORDIA ID NUMBER
MI17629OtherPROVIDER ID NUMBER
MID176290OtherPROVIDER ID NUMBER