Kevin Jay Shively Jr., DMD

Primary specialty

DentistTaxonomy code 122300000X

License

34543 Issued in TX

Practice address

12219 Quaker Ave Ste a
Lubbock, TX 79424-7783

Phone

(806) 698-8660

Fax

(806) 319-3878

NPI assigned

Aug 2, 2013

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1375401600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1615939200000",
    "number": "1588096390",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12219 QUAKER AVE STE A",
            "city": "LUBBOCK",
            "state": "TX",
            "postal_code": "794247783",
            "telephone_number": "806-698-8660",
            "fax_number": "806-319-3878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12219 QUAKER AVE STE A",
            "city": "LUBBOCK",
            "state": "TX",
            "postal_code": "794247783",
            "telephone_number": "806-698-8660",
            "fax_number": "806-319-3878"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "Unit 28038",
            "address_2": "USA Dentac Bavaria",
            "address_purpose": "LOCATION",
            "city": "APO",
            "state": "AE",
            "postal_code": "09112",
            "country_code": "US",
            "telephone_number": "011499622834738",
            "country_name": "United States",
            "address_type": "MIL"
        }
    ],
    "basic": {
        "last_name": "SHIVELY",
        "first_name": "KEVIN",
        "middle_name": "JAY",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-08-02",
        "last_updated": "2021-03-17",
        "certification_date": "2021-03-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "TX",
            "license": "34543",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dentist in Lubbock, TX
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.