Provider Demographics
NPI:1053442483
Name:SHELKO, RAYMOND ANTHONY (DDS)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:ANTHONY
Last Name:SHELKO
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 1:1090 GOAT SPRINGS ROAD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1946
Mailing Address - Country:US
Mailing Address - Phone:575-758-4224
Mailing Address - Fax:575-751-5210
Practice Address - Street 1:1090 GOAT SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-1946
Practice Address - Country:US
Practice Address - Phone:575-758-4224
Practice Address - Fax:575-751-5210
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK3543Medicaid
NM49382861Medicaid
NM49382861Medicaid
NM320057Medicare Oscar/Certification