Provider Demographics
NPI:1982787024
Name:SHANNON, MICHAEL DEAN (DSS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DEAN
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 MAIN ST S
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3956
Mailing Address - Country:US
Mailing Address - Phone:701-839-7288
Mailing Address - Fax:701-839-1574
Practice Address - Street 1:315 MAIN ST S
Practice Address - Street 2:SUITE 302
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3956
Practice Address - Country:US
Practice Address - Phone:701-839-7288
Practice Address - Fax:701-839-1574
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND18541223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics