Provider Demographics
NPI:1811364599
Name:SHIREY, NICHOLAS (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:SHIREY
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 1:1704 MALLARD COVE DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9503
Mailing Address - Country:US
Mailing Address - Phone:717-965-6067
Mailing Address - Fax:
Practice Address - Street 1:9416 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4157
Practice Address - Country:US
Practice Address - Phone:734-455-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022928122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty