Basic Information
| Provider Information | |||||||||
| NPI: | 1558751180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.D.H. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 119 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318612130 | ||||||||
| FaxNumber: | 2318614964 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318612130 | ||||||||
| FaxNumber: | 2318614964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2902012812 | MI | Y | Dental Providers | Dental Hygienist |
No ID Information.