Healthcare Provider Details

I. General information

NPI: 1184857633
Provider Name (Legal Business Name): JACK CLIFTON SHROPSHIRE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 09/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 BROADWAY STE 5
LUBBOCK TX
79401-3209
US

IV. Provider business mailing address

15 ARAPAHO RD
RANSOM CANYON TX
79366-2216
US

V. Phone/Fax

Practice location:
  • Phone: 806-765-2605
  • Fax: 806-687-5957
Mailing address:
  • Phone: 806-829-2550
  • Fax: 806-687-5957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8720
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: