Provider Demographics
NPI:1073593992
Name:MCCOLM, SHELLY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:L
Last Name:MCCOLM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 INGE CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4835
Mailing Address - Country:US
Mailing Address - Phone:785-832-1782
Mailing Address - Fax:
Practice Address - Street 1:12 W 8TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2602
Practice Address - Country:US
Practice Address - Phone:785-832-0809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS70611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKS7061Other7061