Provider Demographics
NPI:1275924144
Name:MOORE, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 E ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:AU GRES
Mailing Address - State:MI
Mailing Address - Zip Code:48703-9682
Mailing Address - Country:US
Mailing Address - Phone:989-876-4040
Mailing Address - Fax:989-654-2348
Practice Address - Street 1:5095 RIFLE RIVER TRL
Practice Address - Street 2:
Practice Address - City:ALGER
Practice Address - State:MI
Practice Address - Zip Code:48610-9327
Practice Address - Country:US
Practice Address - Phone:989-873-5152
Practice Address - Fax:989-873-5913
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016066124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist