Healthcare Provider Details

I. General information

NPI: 1912103946
Provider Name (Legal Business Name): MICHAEL JOSEPH SHANNON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13360 COURSEY BLVD STE D
BATON ROUGE LA
70816-5024
US

IV. Provider business mailing address

13360 COURSEY BLVD STE D
BATON ROUGE LA
70816-4970
US

V. Phone/Fax

Practice location:
  • Phone: 225-752-1252
  • Fax: 225-752-8348
Mailing address:
  • Phone: 225-752-1252
  • Fax: 225-752-8348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5277
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: