Provider Demographics
NPI:1073213658
Name:TACEY, SHELBY NICOLE (RDH)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:TACEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:NICOLE
Other - Last Name:PEDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:175 CASS AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:MUNGER
Mailing Address - State:MI
Mailing Address - Zip Code:48747-9719
Mailing Address - Country:US
Mailing Address - Phone:469-847-1866
Mailing Address - Fax:
Practice Address - Street 1:2614 CENTER AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6300
Practice Address - Country:US
Practice Address - Phone:989-402-0510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902019648124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist