=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649205725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON D LAWSON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 S MAIN ST STE B
-----------------------------------------------------
City | TOOELE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84074-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-882-2755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232 S MAIN ST
-----------------------------------------------------
City | TOOELE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84074-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-882-2755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 294357-9923
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------