Provider Demographics
NPI:1528105079
Name:VERT, MICHAEL SHANE
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
Last Name:VERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10805 PARAMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241
Mailing Address - Country:US
Mailing Address - Phone:562-869-1686
Mailing Address - Fax:562-861-1672
Practice Address - Street 1:10805 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3308
Practice Address - Country:US
Practice Address - Phone:562-869-1686
Practice Address - Fax:562-861-1672
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry