Healthcare Provider Details

I. General information

NPI: 1780698845
Provider Name (Legal Business Name): THOMAS R SHANNON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 OLD HOOK RD SUITE 201
WESTWOOD NJ
07675-3246
US

IV. Provider business mailing address

354 OLD HOOK RD SUITE 201
WESTWOOD NJ
07675-3246
US

V. Phone/Fax

Practice location:
  • Phone: 201-664-3023
  • Fax: 201-664-0912
Mailing address:
  • Phone: 201-664-3023
  • Fax: 201-664-0912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberTRS-9532
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: