Provider Demographics
NPI:1417247529
Name:SHIRLEY, LINDSAY L (DDS)
Entity type:Individual
Prefix:DR
First Name:LINDSAY
Middle Name:L
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:L
Other - Last Name:PORATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:30 BLUEBERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439
Mailing Address - Country:US
Mailing Address - Phone:850-835-4127
Mailing Address - Fax:
Practice Address - Street 1:30 BLUEBERRY ROAD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:FL
Practice Address - Zip Code:32439
Practice Address - Country:US
Practice Address - Phone:850-835-4127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-10
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN210611223G0001X
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program