Healthcare Provider Details

I. General information

NPI: 1972433514
Provider Name (Legal Business Name): MADELINE SHANK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 W MAPLE RD # 200
WEST BLOOMFIELD MI
48322-3004
US

IV. Provider business mailing address

6565 MAPLE LAKES CT
WEST BLOOMFIELD MI
48322-3059
US

V. Phone/Fax

Practice location:
  • Phone: 248-489-5950
  • Fax:
Mailing address:
  • Phone: 616-432-1772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901603035
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: