Provider Demographics
NPI:1467120329
Name:SHORT, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SHORT
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 1:9 SARGENT RD
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-5903
Mailing Address - Country:US
Mailing Address - Phone:120-140-3750
Mailing Address - Fax:
Practice Address - Street 1:1040 BROAD ST
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4331
Practice Address - Country:US
Practice Address - Phone:813-539-4062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22HI00938400124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist