Provider Demographics
NPI:1700268802
Name:SHANNON ORTHODONTICS LLC
Entity Type:Organization
Organization Name:SHANNON ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-562-2782
Mailing Address - Street 1:39863 HIGHWAY 27 STE 8
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-7802
Mailing Address - Country:US
Mailing Address - Phone:863-353-6867
Mailing Address - Fax:863-353-6869
Practice Address - Street 1:39863 HIGHWAY 27 STE 8
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-7802
Practice Address - Country:US
Practice Address - Phone:863-353-6867
Practice Address - Fax:863-353-6869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL201771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty