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General NPI Number Information
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NPI Number | 1962790261
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Entity Type | Organization
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Legal Business Name | AJ SHANNON DMD PLC
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Dates
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Enumeration Date | 07/20/2011
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Last Update Date | 07/20/2011
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Provider Practice Location Address
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Address Line | 301 MAPLE AVE W SUITE 200
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City | VIENNA
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State | VA
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Zip | 22180-4301
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Country | US
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Telephone | 703-319-8370
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Fax | 703-319-8371
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Provider Business Mailing Address
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Address Line | 301 MAPLE AVE W SUITE 200
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City | VIENNA
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State | VA
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Zip | 22180-4301
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Country | US
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Telephone | 703-319-8370
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Fax | 703-319-8371
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Authorized Official
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Title or Position | DENTIST
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Name | ANDREW JASON SHANNON
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Credential | DMD
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Telephone | 571-230-8051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401411773
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License Number State | VA
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