Healthcare Provider Details

I. General information

NPI: 1497980924
Provider Name (Legal Business Name): CHILDRENS DENTISTRY OF WESTERLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GRANITE ST # C
WESTERLY RI
02891-2461
US

IV. Provider business mailing address

130 GRANITE ST # C
WESTERLY RI
02891-2461
US

V. Phone/Fax

Practice location:
  • Phone: 401-596-8720
  • Fax: 401-596-5403
Mailing address:
  • Phone: 401-596-8720
  • Fax: 401-596-5403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2263
License Number StateRI

VIII. Authorized Official

Name: DR. BRIAN PAUL SHANNON
Title or Position: OWNER
Credential: D.D.S
Phone: 401-596-8720