Provider Demographics
NPI:1447661186
Name:DR. EDWIN KENT SHIRLEY
Entity type:Organization
Organization Name:DR. EDWIN KENT SHIRLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF DENTAL SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-235-8402
Mailing Address - Street 1:1231 27TH ST S
Mailing Address - Street 2:STE 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:
Practice Address - Street 1:1231 27TH ST S
Practice Address - Street 2:STE 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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1596122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND132811Medicaid