Healthcare Provider Details

I. General information

NPI: 1780801183
Provider Name (Legal Business Name): KYLE SHANNON D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 E 41ST ST SUITE 112
TULSA OK
74105-3717
US

IV. Provider business mailing address

3150 E 41ST ST SUITE 112
TULSA OK
74105-3717
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-2321
  • Fax: 918-749-5121
Mailing address:
  • Phone: 918-743-2321
  • Fax: 918-749-5121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5410
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: