Provider Demographics
NPI:1093384828
Name:SHANAHAN, MORGAN MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MORGAN
Middle Name:MARIE
Last Name:SHANAHAN
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 1:5803 W CHADWORTH CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-6613
Mailing Address - Country:US
Mailing Address - Phone:309-219-5803
Mailing Address - Fax:
Practice Address - Street 1:809 W CAMP ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-7218
Practice Address - Country:US
Practice Address - Phone:309-694-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist