Provider Demographics
NPI:1760644132
Name:SHANNON, THOMAS PATRICK (DDS, MDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PATRICK
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DDS, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 44TH ST SW
Mailing Address - Street 2:NONE
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2300
Mailing Address - Country:US
Mailing Address - Phone:616-238-8387
Mailing Address - Fax:
Practice Address - Street 1:4320 44TH ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2300
Practice Address - Country:US
Practice Address - Phone:616-534-0550
Practice Address - Fax:616-534-1334
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2015-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44691223G0001X
MI29010195651223G0001X, 1223X0400X
MNS471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice