Provider Demographics
NPI:1083762199
Name:SHIVELY, HARRY MARTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:MARTIN
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3233 VALENCIA AVE
Mailing Address - Street 2:SUITE B-3
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-4157
Mailing Address - Country:US
Mailing Address - Phone:831-662-2777
Mailing Address - Fax:831-688-2022
Practice Address - Street 1:3233 VALENCIA AVE
Practice Address - Street 2:SUITE B-3
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-4157
Practice Address - Country:US
Practice Address - Phone:831-662-2777
Practice Address - Fax:831-688-2022
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA323961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice