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General NPI Number Information
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NPI Number | 1922415223
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Entity Type | Individual
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Provider Name | TALIA MARIE SHACKELFORD DDS
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Gender | Female
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Dates
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Enumeration Date | 07/18/2014
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Last Update Date | 07/18/2014
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Provider Practice Location Address
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Address Line | 4216 24TH AVE
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City | FORT GRATIOT
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State | MI
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Zip | 48059-3880
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Country | US
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Telephone | 810-479-4821
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Fax |
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Provider Business Mailing Address
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Address Line | 3350 CRESTWATER CT APT 1812
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City | ROCHESTER HILLS
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State | MI
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Zip | 48309-2780
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Country | US
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Telephone | 714-345-3086
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901021371
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License Number State | MI
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