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General NPI Number Information
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NPI Number | 1366746117
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Entity Type | Individual
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Provider Name | JACK A SHANNON DDS
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Gender | Male
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Dates
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Enumeration Date | 01/07/2011
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Last Update Date | 01/07/2011
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Provider Practice Location Address
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Address Line | 601 S 124TH ST. WEST
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City | TAFT
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State | OK
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Zip | 74463
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Country | US
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Telephone | 918-682-7841
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Fax | 918-682-6107
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Provider Business Mailing Address
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Address Line | 9807 S 225TH EAST AVE
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City | BROKEN ARROW
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State | OK
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Zip | 74014-5928
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Country | US
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Telephone | 918-519-5751
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5531
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License Number State | OK
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