Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 014746 | MI |
NPI | 1003926494 |
---|---|
Provider Name | Mrs. Therese F Shortt |
First Address | South Lyon, MI 48178 |
Second Address | South Lyon, MI 48178 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 08/07/2007 |