MEDICARE: DR. SHANNON CAROL CUNNINGHAM D.D.S.

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	1223G0001X	General Practice Dentistry	D11160	MN

General Provider Information

NPI Number	:	1770681173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON CAROL CUNNINGHAM D.D.S.

Provider Business Mailing Address
First Line	:	1956 JULIET AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1722
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7430 80TH ST S
Second Line	:	SUITE 202
City	:	COTTAGE GROVE
State	:	MN
Zip	:	55016-3035
Country	:	US
Telephone Number	:	651-459-6884
Fax Number	:	651-459-5670

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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