Healthcare Provider Details

I. General information

NPI: 1467650598
Provider Name (Legal Business Name): STEPHEN PATRICK SHANNON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13360 COURSEY BLVD SUITE C
BATON ROUGE LA
70816
US

IV. Provider business mailing address

13360 COURSEY BLVD SUITE C
BATON ROUGE LA
70816
US

V. Phone/Fax

Practice location:
  • Phone: 225-752-8348
  • Fax:
Mailing address:
  • Phone: 225-752-8348
  • Fax: 225-752-8352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5278
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: