Provider Demographics
NPI:1336756436
Name:SHANNON CANDID LOUISIANA, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHANNON CANDID LOUISIANA, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-481-7631
Mailing Address - Street 1:804 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-5528
Mailing Address - Country:US
Mailing Address - Phone:860-481-7631
Mailing Address - Fax:
Practice Address - Street 1:804 MAIN ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-5528
Practice Address - Country:US
Practice Address - Phone:860-481-7631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty