Provider Demographics
NPI:1275713570
Name:SHIVELY, MAURICE ANTHONY (DDS)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:ANTHONY
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969
Mailing Address - Country:US
Mailing Address - Phone:906-358-4587
Mailing Address - Fax:906-358-4118
Practice Address - Street 1:E23970 POW WOW TRAIL RD
Practice Address - Street 2:
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969
Practice Address - Country:US
Practice Address - Phone:906-358-4587
Practice Address - Fax:906-358-4118
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901009716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist