Provider Demographics
NPI:1467542852
Name:SHANNON, MICHAEL E (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7118
Mailing Address - Country:US
Mailing Address - Phone:509-783-0824
Mailing Address - Fax:509-783-9136
Practice Address - Street 1:800 N CENTER PKWY
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7118
Practice Address - Country:US
Practice Address - Phone:509-783-0824
Practice Address - Fax:509-783-9136
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000047971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE00004797OtherSTATE DENTAL LICENSE