Individual
MARY VIVIANNE SHANNON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
11980 SAN VICENTE BLVD STE 906, LOS ANGELES, CA 90049-6607
(310) 998-8999
(310) 998-8999
Mailing address
357 S GLENROY AVE, LOS ANGELES, CA 90049-3136
(310) 869-1332
(310) 471-3897
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
48769
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
D48769
—
CA
Enumeration date
01/29/2007
Last updated
09/26/2012
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