Provider Demographics
NPI:1093198301
Name:SHIELDS, NASTASSIA ELENA (DMD)
Entity Type:Individual
Prefix:DR
First Name:NASTASSIA
Middle Name:ELENA
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7319 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-6746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7319 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-6746
Practice Address - Country:US
Practice Address - Phone:407-294-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058481122300000X
FLDN218161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist