MEDICARE: DR. MICHAEL DALE SHIRLEY D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS0000005139	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0160274	OTHER	TN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1295719532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DALE SHIRLEY D.D.S.

Provider Business Mailing Address
First Line	:	4302 SUMMER AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38122-4000
Country	:	US
Telephone Number	:	901-683-3849
Fax Number	:	901-685-7734

Provider Business Practice Location Address
First Line	:	4302 SUMMER AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38122-4000
Country	:	US
Telephone Number	:	901-683-3849
Fax Number	:	901-685-7734

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. MICHAEL DALE SHIRLEY D.D.S.” Practice Location

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