Provider Demographics
NPI:1033217039
Name:SHELTON, ERIC WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WAYNE
Last Name:SHELTON
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 1:501 SANFORD ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101
Mailing Address - Country:US
Mailing Address - Phone:563-382-2441
Mailing Address - Fax:563-382-6048
Practice Address - Street 1:501 SANFORD ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101
Practice Address - Country:US
Practice Address - Phone:563-382-2441
Practice Address - Fax:563-382-6048
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1262162Medicaid