Healthcare Provider Details

I. General information

NPI: 1104423672
Provider Name (Legal Business Name): SHELBY D MAURICE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 ROSE ST
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

21582 S ELLSWORTH LOOP RD STE 126
QUEEN CREEK AZ
85142-7882
US

V. Phone/Fax

Practice location:
  • Phone: 859-568-2669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11002
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number105665
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901602957
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: