Provider Demographics
NPI:1528201902
Name:SHANAHAN, TIMOTHY M (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:SHANAHAN
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 1:3941 75TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7924
Mailing Address - Country:US
Mailing Address - Phone:630-375-8380
Mailing Address - Fax:630-375-8378
Practice Address - Street 1:3941 75TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7924
Practice Address - Country:US
Practice Address - Phone:630-375-8380
Practice Address - Fax:630-375-8378
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0191741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice