MEDICARE: DR. SHANNON DUQUM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	30.024729	OH

General Provider Information

NPI Number	:	1528419728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON DUQUM DDS

Provider Business Mailing Address
First Line	:	220 E MAIN ST
Second Line	:
City	:	GENEVA
State	:	OH
Zip	:	44041-1481
Country	:	US
Telephone Number	:	440-466-4884
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 E MAIN ST
Second Line	:
City	:	GENEVA
State	:	OH
Zip	:	44041-1481
Country	:	US
Telephone Number	:	440-466-4884
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2016
Last Update Date	:	03/21/2023

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