Provider Demographics
NPI:1710208053
Name:DAVIDSON, SHANE TERRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:TERRY
Last Name:DAVIDSON
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 1:297 HERSHEY BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-2435
Mailing Address - Country:US
Mailing Address - Phone:248-860-2031
Mailing Address - Fax:248-499-6424
Practice Address - Street 1:7805 COOLEY LAKE RD STE 400
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-3535
Practice Address - Country:US
Practice Address - Phone:248-977-3006
Practice Address - Fax:248-242-6762
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010202221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice