Provider Demographics
NPI:1760687800
Name:COLE, SHANNON ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:COLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 COLUMBIA RD
Mailing Address - Street 2:APT.#8J
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4019
Mailing Address - Country:US
Mailing Address - Phone:617-905-3354
Mailing Address - Fax:
Practice Address - Street 1:73 GLEN COVE RD
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1007
Practice Address - Country:US
Practice Address - Phone:516-621-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0535301223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics