Provider Demographics
NPI:1235533241
Name:SHANNON KEYES DMD LLC
Entity Type:Organization
Organization Name:SHANNON KEYES DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:M
Authorized Official - Last Name:KEYES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-971-7900
Mailing Address - Street 1:34 MANCHESTER AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1366
Mailing Address - Country:US
Mailing Address - Phone:609-971-7900
Mailing Address - Fax:609-971-7799
Practice Address - Street 1:34 MANCHESTER AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1366
Practice Address - Country:US
Practice Address - Phone:609-971-7900
Practice Address - Fax:609-971-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO21917001223G0001X
NJ22DIO1011507011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty