MEDICARE: MARY VIVIANNE SHANNON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	48769	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760528525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY VIVIANNE SHANNON DDS

Provider Business Mailing Address
First Line	:	357 S GLENROY AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-3136
Country	:	US
Telephone Number	:	310-869-1332
Fax Number	:	310-471-3897

Provider Business Practice Location Address
First Line	:	11980 SAN VICENTE BLVD STE 906
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-6607
Country	:	US
Telephone Number	:	310-998-8999
Fax Number	:	310-998-8999

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	09/26/2012

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