Provider Demographics
NPI:1902921489
Name:SHIRLEY, THOMAS HERBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HERBERT
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 1:307 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4861
Mailing Address - Country:US
Mailing Address - Phone:337-463-3036
Mailing Address - Fax:337-463-8554
Practice Address - Street 1:307 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4861
Practice Address - Country:US
Practice Address - Phone:337-463-3036
Practice Address - Fax:337-463-8554
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA30901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice