Provider Demographics
NPI:1891188868
Name:SHANNON, AMY (RDH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MANCHESTER ST
Mailing Address - Street 2:SUITE #5
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:153 MANCHESTER ST
Practice Address - Street 2:SUITE #5
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5142
Practice Address - Country:US
Practice Address - Phone:603-224-9474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-14
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02356124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist