Healthcare Provider Details

I. General information

NPI: 1235533241
Provider Name (Legal Business Name): SHANNON KEYES DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MANCHESTER AVE SUITE 204
FORKED RIVER NJ
08731-1366
US

IV. Provider business mailing address

34 MANCHESTER AVE SUITE 204
FORKED RIVER NJ
08731-1366
US

V. Phone/Fax

Practice location:
  • Phone: 609-971-7900
  • Fax: 609-971-7799
Mailing address:
  • Phone: 609-971-7900
  • Fax: 609-971-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DIO2191700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DIO101150701
License Number StateNJ

VIII. Authorized Official

Name: DR. SHANNON M KEYES
Title or Position: DENTIST
Credential: DMD
Phone: 609-971-7900