Provider Demographics
NPI:1295719532
Name:SHIRLEY, MICHAEL DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DALE
Last Name:SHIRLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 SUMMER AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-4000
Mailing Address - Country:US
Mailing Address - Phone:901-683-3849
Mailing Address - Fax:901-685-7734
Practice Address - Street 1:4302 SUMMER AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-4000
Practice Address - Country:US
Practice Address - Phone:901-683-3849
Practice Address - Fax:901-685-7734
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000051391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0160274OtherBLUE CROSS BLUE SHIELD