Provider Demographics
NPI:1932889995
Name:SHANNON, EILEEN KAY (DDS)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:KAY
Last Name:SHANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 BELLONA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3500
Mailing Address - Country:US
Mailing Address - Phone:410-323-2875
Mailing Address - Fax:
Practice Address - Street 1:5710 BELLONA AVE STE 101
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3500
Practice Address - Country:US
Practice Address - Phone:410-323-2875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7954122300000X
MD18743122300000X
IL019035799122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist