Provider Demographics
NPI:1558751180
Name:LARSON, SHANNON MARIE (RDH)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MI
Mailing Address - Zip Code:49455-1243
Mailing Address - Country:US
Mailing Address - Phone:231-861-2130
Mailing Address - Fax:231-861-4964
Practice Address - Street 1:119 S STATE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-1243
Practice Address - Country:US
Practice Address - Phone:231-861-2130
Practice Address - Fax:231-861-4964
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902012812124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist