Provider Demographics
NPI:1003834763
Name:HAAS, SHELLY K (DMD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:K
Last Name:HAAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:K
Other - Last Name:MCCARTHY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14601 PURITAS AVENUE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44315
Mailing Address - Country:US
Mailing Address - Phone:216-671-5452
Mailing Address - Fax:216-671-5455
Practice Address - Street 1:14601 PURITAS AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135
Practice Address - Country:US
Practice Address - Phone:216-671-5452
Practice Address - Fax:216-671-5455
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0215921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2372132Medicaid