Provider Demographics
NPI:1770641128
Name:SHANNON, TIMOTHY PATRICK (DMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7524 SE 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-8533
Mailing Address - Country:US
Mailing Address - Phone:503-771-1106
Mailing Address - Fax:503-654-7774
Practice Address - Street 1:4450 SE JOHNSON CREEK BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-9217
Practice Address - Country:US
Practice Address - Phone:503-654-7773
Practice Address - Fax:503-654-7774
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice