Provider Demographics
NPI:1801860747
Name:O'BANNON, SHAWN PATRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:PATRICK
Last Name:O'BANNON
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 1:2408 SOUTH LAMAR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655
Mailing Address - Country:US
Mailing Address - Phone:662-236-2461
Mailing Address - Fax:
Practice Address - Street 1:2408 SOUTH LAMAR
Practice Address - Street 2:SUITE 2
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-236-2461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL50291223X0400X
MS3522-091223X0400X
TN90821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics