Provider Demographics
NPI:1699394916
Name:SHANNON, CAITLIN SUZANNE (DDS)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:SUZANNE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:SUZANNE
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4200 W COUNTY ROAD 100 S
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-2578
Mailing Address - Country:US
Mailing Address - Phone:317-617-8373
Mailing Address - Fax:
Practice Address - Street 1:2519 E MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-5869
Practice Address - Country:US
Practice Address - Phone:765-962-1519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN12013403A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program