Provider Demographics
NPI:1336481431
Name:SHACKLEFORD, KATHERINE (DDS)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 CHAMPAIGN RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3303
Mailing Address - Country:US
Mailing Address - Phone:313-386-9660
Mailing Address - Fax:
Practice Address - Street 1:1359 CHAMPAIGN RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3303
Practice Address - Country:US
Practice Address - Phone:313-386-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist