Provider Demographics
NPI:1902098817
Name:SHUCK, MICHAEL C (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:SHUCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:C
Other - Last Name:SHUCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1480-2A QUARTERPATH ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185
Mailing Address - Country:US
Mailing Address - Phone:757-345-2295
Mailing Address - Fax:
Practice Address - Street 1:1480-2A QUARTERPATH ROAD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-345-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014118341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice