Provider Demographics
NPI:1801907142
Name:SHIREY, J THAD (DDS)
Entity type:Individual
Prefix:DR
First Name:J
Middle Name:THAD
Last Name:SHIREY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:T
Other - Last Name:SHIREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 477
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927
Mailing Address - Country:US
Mailing Address - Phone:479-675-2009
Mailing Address - Fax:479-675-5446
Practice Address - Street 1:1090 HWY 10 EAST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927
Practice Address - Country:US
Practice Address - Phone:479-675-2009
Practice Address - Fax:479-675-5446
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2222122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist