Provider Demographics
NPI:1982828497
Name:SHANNON, SHAWN PATRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
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 1:285 SILLS RD
Mailing Address - Street 2:BLDG 15 SUITE F
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:631-654-1040
Mailing Address - Fax:631-654-1105
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:BLDG 15 SUITE F
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4869
Practice Address - Country:US
Practice Address - Phone:631-654-1040
Practice Address - Fax:631-654-1105
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048505122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist