Provider Demographics
NPI:1083928782
Name:SHANNON, JENNIFER (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHANNON
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 1:4400 DEER PATH RD STE 101
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-3908
Mailing Address - Country:US
Mailing Address - Phone:717-364-5986
Mailing Address - Fax:
Practice Address - Street 1:4400 DEER PATH RD STE 101
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-3908
Practice Address - Country:US
Practice Address - Phone:717-364-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038393122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist