Provider Demographics
NPI:1508024787
Name:SHAUGHNESSY, BRIAN THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:THOMAS
Last Name:SHAUGHNESSY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6532 ANTHONY DR STE C
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-1403
Mailing Address - Country:US
Mailing Address - Phone:585-869-5314
Mailing Address - Fax:
Practice Address - Street 1:6532 ANTHONY DR STE C
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1403
Practice Address - Country:US
Practice Address - Phone:585-869-5314
Practice Address - Fax:585-869-5314
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-24
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019770122300000X
NY0569441223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI019770OtherDELTA DENTAL
MI381908328OtherASSURANT