Provider Demographics
NPI:1194775502
Name:SHOCKLEY, RICHARD A (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:SHOCKLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5310
Mailing Address - Country:US
Mailing Address - Phone:269-323-1679
Mailing Address - Fax:269-323-1536
Practice Address - Street 1:706 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5310
Practice Address - Country:US
Practice Address - Phone:269-323-1679
Practice Address - Fax:269-323-1536
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010114001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2908240Medicaid