Healthcare Provider Details

I. General information

NPI: 1265095764
Provider Name (Legal Business Name): CANDID MICHIGAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 UNION SQ W FL 2
NEW YORK NY
10003-3235
US

IV. Provider business mailing address

41 UNION SQ W FL 2
NEW YORK NY
10003-3235
US

V. Phone/Fax

Practice location:
  • Phone: 702-738-5334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS SHANNON
Title or Position: PRESIDENT
Credential:
Phone: 702-738-5334