Provider Demographics
NPI:1801564026
Name:SHIRLEY, TANYA RENE (RDH)
Entity type:Individual
Prefix:MS
First Name:TANYA
Middle Name:RENE
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:TANYA
Other - Middle Name:ENE
Other - Last Name:SHIRLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:3595 CARDINAL POINT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5500
Mailing Address - Country:US
Mailing Address - Phone:904-737-2040
Mailing Address - Fax:
Practice Address - Street 1:3595 CARDINAL POINT DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5500
Practice Address - Country:US
Practice Address - Phone:904-737-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH20661124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty