Provider Demographics
NPI:1659793115
Name:SHANNON M. COEN D.M.D, PC
Entity Type:Organization
Organization Name:SHANNON M. COEN D.M.D, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:M
Authorized Official - Last Name:COEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:651-398-9686
Mailing Address - Street 1:16080 N 59TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-2339
Mailing Address - Country:US
Mailing Address - Phone:651-398-9686
Mailing Address - Fax:
Practice Address - Street 1:16080 N 59TH AVE STE A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-2339
Practice Address - Country:US
Practice Address - Phone:651-398-9686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7588261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental