Provider Demographics
NPI:1588096390
Name:SHIVELY, KEVIN JAY JR (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAY
Last Name:SHIVELY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12219 QUAKER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-7783
Mailing Address - Country:US
Mailing Address - Phone:806-698-8660
Mailing Address - Fax:806-319-3878
Practice Address - Street 1:12219 QUAKER AVE STE A
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-7783
Practice Address - Country:US
Practice Address - Phone:806-698-8660
Practice Address - Fax:806-319-3878
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34543122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist