Provider Demographics
NPI:1457402687
Name:ERNY, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ERNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W 40TH ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2108
Mailing Address - Country:US
Mailing Address - Phone:410-235-8525
Mailing Address - Fax:410-235-2006
Practice Address - Street 1:711 W 40TH ST
Practice Address - Street 2:SUITE 215
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2108
Practice Address - Country:US
Practice Address - Phone:410-235-8525
Practice Address - Fax:410-235-2006
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD129241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice