Provider Demographics
NPI:1346283843
Name:HAYNES, SHANNON (DDS, INC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:HAYNES
Suffix:
Gender:F
Credentials:DDS, INC
Other - Prefix:DR
Other - First Name:VERA
Other - Middle Name:SHANNON
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, INC
Mailing Address - Street 1:311 LENNON LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2418
Mailing Address - Country:US
Mailing Address - Phone:925-938-7900
Mailing Address - Fax:925-938-7901
Practice Address - Street 1:311 LENNON LN
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2418
Practice Address - Country:US
Practice Address - Phone:925-938-7900
Practice Address - Fax:925-938-7901
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA471184101OtherTAX ID NUMBER