Provider Demographics
NPI:1114976321
Name:SHANNON, NIKOLAI JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:NIKOLAI
Middle Name:JOHN
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 N DETROIT ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2268
Mailing Address - Country:US
Mailing Address - Phone:937-372-7625
Mailing Address - Fax:937-372-7626
Practice Address - Street 1:260 N DETROIT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2268
Practice Address - Country:US
Practice Address - Phone:937-372-7625
Practice Address - Fax:937-372-7626
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14469122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAS6000020OtherBNDD FEDERAL NUMBER