Provider Demographics
NPI:1669477154
Name:SHORTER, FRED (DDS)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:SHORTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:FRED
Other - Middle Name:
Other - Last Name:SHORTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:20100 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3374
Mailing Address - Country:US
Mailing Address - Phone:313-255-2150
Mailing Address - Fax:313-255-6152
Practice Address - Street 1:20100 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3374
Practice Address - Country:US
Practice Address - Phone:313-255-2150
Practice Address - Fax:313-255-6152
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010101851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4199929Medicaid