Provider Demographics
NPI:1679069918
Name:VAIL, SHANNON LYNDEN (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LYNDEN
Last Name:VAIL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 ADMIRAL TAUSSIG BLVD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23511-2803
Mailing Address - Country:US
Mailing Address - Phone:151-953-8509
Mailing Address - Fax:
Practice Address - Street 1:1647 ADMIRAL TAUSSIG BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2803
Practice Address - Country:US
Practice Address - Phone:151-953-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD164181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty