Provider Demographics
NPI:1669599924
Name:SHANNON, TRAVIS M
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:M
Last Name:SHANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 MILLWHEEL LN
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-4734
Mailing Address - Country:US
Mailing Address - Phone:540-387-2855
Mailing Address - Fax:
Practice Address - Street 1:3533 KEAGY RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7312
Practice Address - Country:US
Practice Address - Phone:540-989-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014104891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1778847OtherUNITED CONCORDIA PROVIDER
VA246519OtherANTHEM VA PROVIDER NUMBER