Provider Demographics
NPI:1982825097
Name:SHANNON, ANDREW JASON (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JASON
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 1:301 MAPLE AVE W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4308
Mailing Address - Country:US
Mailing Address - Phone:571-230-8915
Mailing Address - Fax:
Practice Address - Street 1:301 MAPLE AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4308
Practice Address - Country:US
Practice Address - Phone:571-230-8915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014117731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry