Provider Demographics
NPI:1932229333
Name:SHIRLEY, EDWIN KENT (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:KENT
Last Name:SHIRLEY
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 1:1231 27TH ST S
Mailing Address - Street 2:SUITE B
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8722
Mailing Address - Country:US
Mailing Address - Phone:701-235-8402
Mailing Address - Fax:701-271-0317
Practice Address - Street 1:1231 27TH ST S
Practice Address - Street 2:SUITE B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8722
Practice Address - Country:US
Practice Address - Phone:701-235-8402
Practice Address - Fax:701-271-0317
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1596122300000X
MND9436122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40653Medicaid