Provider Demographics
NPI:1922800929
Name:M SHANNON DAUGHERTY DMD, PC
Entity type:Organization
Organization Name:M SHANNON DAUGHERTY DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-699-3636
Mailing Address - Street 1:200 GROVE PARK LN STE 600
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-5921
Mailing Address - Country:US
Mailing Address - Phone:334-699-3636
Mailing Address - Fax:
Practice Address - Street 1:200 GROVE PARK LN STE 600
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-5921
Practice Address - Country:US
Practice Address - Phone:334-699-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty