MEDICARE: DR. SHANE TERRY DAVIDSON 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	2901020222	MI

General Provider Information

NPI Number	:	1710208053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANE TERRY DAVIDSON D.D.S.

Provider Business Mailing Address
First Line	:	297 HERSHEY BLVD
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48327-2435
Country	:	US
Telephone Number	:	248-860-2031
Fax Number	:	248-499-6424

Provider Business Practice Location Address
First Line	:	7805 COOLEY LAKE RD STE 400
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-3535
Country	:	US
Telephone Number	:	248-977-3006
Fax Number	:	248-242-6762

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

Provider Enumeration Date	:	06/22/2010
Last Update Date	:	08/08/2023

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