Provider Demographics
NPI:1669931721
Name:DANIEL, SHIRLEY JENNIFER (DDS)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:JENNIFER
Last Name:DANIEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:JENNIFER
Other - Last Name:ETIENNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2705 MANASCO LN APT 7
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-6614
Mailing Address - Country:US
Mailing Address - Phone:678-790-9730
Mailing Address - Fax:
Practice Address - Street 1:6941 EASTCHASE LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-6876
Practice Address - Country:US
Practice Address - Phone:334-603-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD006612-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice