Provider Demographics
NPI:1497900914
Name:KOENIG, SHANNON MARA COEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARA COEN
Last Name:KOENIG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:MARA
Other - Last Name:COEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:16080 N 59TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-2339
Mailing Address - Country:US
Mailing Address - Phone:602-978-1100
Mailing Address - Fax:602-419-2244
Practice Address - Street 1:16080 N 59TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-2339
Practice Address - Country:US
Practice Address - Phone:602-978-1100
Practice Address - Fax:602-419-2244
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7588122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist