Provider Demographics
NPI:1225181043
Name:SHIELDS, MICHAEL W (DDS,PC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:DDS,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 TURKEY CANYON RANCH RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80926-9560
Mailing Address - Country:US
Mailing Address - Phone:719-576-0065
Mailing Address - Fax:
Practice Address - Street 1:703 N CASCADE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3205
Practice Address - Country:US
Practice Address - Phone:719-634-3204
Practice Address - Fax:719-634-7603
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO054311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05431OtherSTATE LICENSE NUMBER