Healthcare Provider Details

I. General information

NPI: 1790725380
Provider Name (Legal Business Name): BRIAN PAUL SHANNON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 C GRANITE STREET
WESTERLY RI
02891
US

IV. Provider business mailing address

130 C GRANITE STREET
WESTERLY RI
02891
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:
Title or Position:
Credential:
Phone: