Provider Demographics
NPI:1649392085
Name:SHIELDS, MICHAEL HAROLD (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HAROLD
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 CASTENERA AVE
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-2719
Mailing Address - Country:US
Mailing Address - Phone:228-475-5854
Mailing Address - Fax:228-475-0287
Practice Address - Street 1:4218 CASTENERA AVE
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-2719
Practice Address - Country:US
Practice Address - Phone:228-475-5854
Practice Address - Fax:228-475-0287
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2033-831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060001Medicaid