Healthcare Provider Details

I. General information

NPI: 1801860747
Provider Name (Legal Business Name): SHAWN PATRICK O'BANNON D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 SOUTH LAMAR SUITE 2
OXFORD MS
38655
US

IV. Provider business mailing address

2408 SOUTH LAMAR SUITE 2
OXFORD MS
38655
US

V. Phone/Fax

Practice location:
  • Phone: 662-236-2461
  • Fax:
Mailing address:
  • Phone: 662-236-2461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5029
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3522-09
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9082
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: