Provider Demographics
NPI:1376102426
Name:THOMPSON, SHANNON D (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:D
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 CONNECTICUT AVE NW APT 926
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-1944
Mailing Address - Country:US
Mailing Address - Phone:904-778-5988
Mailing Address - Fax:
Practice Address - Street 1:777 H ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-3626
Practice Address - Country:US
Practice Address - Phone:202-560-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCDEN1002046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program